Sarah Nome has been making waves in her community for years, as a city council watchdog in her hometown of San Anselmo and as a muckraking newspaper reporter for West Marin’s Coastal Post. But she’s never stirred as much controversy as the virtual tsunami she kicked up recently without ever leaving her bed. In fact, her story has been striking fear in the hearts of hospital and nursing home administrators across the country because she wouldn’t leave her bed. For more than a year, she refused to be discharged from Kaiser Permanente until a place was available for her in Marin. It’s been the biggest bedside media event since John and Yoko’s honeymoon.

Nome’s last stand raises important questions not just for the healthcare industry, but also for the elderly and everyone who expects to become elderly. When a patient needs to be sent from a hospital to a skilled nursing facility, the hospital is supposed to keep her until an appropriate placement is available. Patients have the right to be placed close to home. But the facilities also have the right to choose the patients they admit. And nursing homes can be surprisingly picky.

There are a number of ways a patient can be deemed undesirable. One is by not being wealthy. Those who can afford to pay privately—as much as $6,500 a month—can pick the skilled nursing facility of their choice. The facility can ask for a financial disclosure and give first priority to the well-financed. For most of us, however, an extended stay can mean becoming impoverished, sooner or later, and relying on Medi-Cal. As Medi-Cal reimbursements fall further and further short of covering the cost of care, fewer spaces for Medi-Cal patients are available. Most of the skilled nursing homes in Marin accept Medi-Cal as a matter of policy—but in practice, they may limit the number of slots for Medi-Cal patients even when they have vacancies.

Nursing homes also look at how much care a patient needs. They may not have enough staffing to take on too many patients who require a lot of care. Another factor they consider is behavior—not just the patient’s behavior, but the family’s, too. If you file a complaint against your mother’s nursing home, for example, they may try to evict her. “If they don’t like you, they’ll end up transferring your mother to an acute care hospital and they won’t let her back in,” says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. “It’s not legal, but we don’t have any enforcement in California. We had 14,000 complaints filed last year with the Department of Health Services; 75 percent of those were found to be unsubstantiated — not because they didn’t happen, but because by the time the department gets out there to the facility, people are dead!”

In Sarah Nome’s case, there was a $1,000 fine levied against her nursing home for transferring her to Kaiser, then refusing to take her back. The law requires the home to reserve a bed for the patient for when she no longer needs acute care hospitalization. Whether the fine is ever paid is another question—Hillside Care Center is appealing it, and most nursing home fines are never collected. In any case, the home can’t be forced to take Nome back.

Nome’s saga began when she was standing at her sink at home and her legs suddenly crumbled under her. She spent several weeks at Kaiser before they finally set the fragile bones and sent her on to a nursing home. But 15 months later, she was back at Kaiser. Hillside officials claim she threatened to set fire to a pile of newspapers in her room. She says that’s silly—she didn’t have any matches, anyway. Nevertheless, Hillside declared she needed a psychiatric evaluation and dumped her at Kaiser’s emergency room. Kaiser discharge planners spent the following year trying to find another skilled nursing facility for her, with no success. No homes in Marin would take her, and Nome refused to be sent out of the county. It finally took a court order to have her forcibly removed. She was put on a gurney just before dinnertime and whisked across the bay to Lafayette Convalescent Hospital. Looking out the back of the ambulance, Nome watched Mount Tamalpais receding in the distance.

NOME HAS A history of difficult behavior. She was a constant, unwelcome presence at San Anselmo City Council meetings for years, protesting taxes, accusing officials of wastefulness, disrupting proceedings. When she perceived malfeasance, she went after the alleged perpetrators like a bulldog—a trait that endeared her to her publisher at the Coastal Post, but raised hackles at City Hall. These days, even her own lawyer is having trouble with her. Ian Sammis has asked to withdraw from representing her. The judge has denied the request. But Nome won’t answer Sammis’s questions and won’t sign the necessary releases that would allow him access to her medical or financial records.

It seems that Nome is afraid of signing any documents. When I visited her in Lafayette, she showed me a form the nursing home had asked her to sign, specifying what life-sustaining measures she wanted taken in an emergency. Although I’d never met her before, she gave me the unsigned form and asked me to send it to her daughter Jane, who would tell her what to do.

At 82, Nome certainly has her wits about her. The stack of newspapers next to her bed are mostly turned to the New York Times crossword puzzle, which she often completes in about 20 minutes. And she still has a commanding presence, with her piercing gaze and authoritative voice. But she defers to her daughter to fill in many of the details she says she’s forgotten. She also believes there is a microphone in the wall behind her bed and hidden cameras in the track of the curtain. “I know you think it’s Looney Tunes,” she says. “I’m just telling you so that you know everything we say is known. Everything I say I can hear them repeating later, the same phraseology that I use. It’s OK, they’ve got to do that.”

Her daughter Jane is convinced that local officials, county staffers and Kaiser executives are conspiring against her mother. In her court testimony she accused them of a range of elaborate schemes, including racketeering, kidnapping, fraud and embezzlement. As the county commissioner was considering whether to place Nome under the temporary conservatorship of the public guardian, the question was raised whether Jane has exerted “undue influence” over her mother.

Nome and her daughter are fighting the conservatorship. But when pressed for a “yes” or “no” answer, Jane told the court she was unwilling to take her mother home with her. Sarah, on the other hand, has transferred title of her own home to Jane.

While eligibility rules for Medi-Cal put strict limits on a patient’s assets, a home is exempt, as long as the patient intends to return to it. After death, however, the state can place a claim against the house to recover the cost of care. Some seniors decide to protect their children’s inheritance by giving them title to the house before they die. “When someone says to me, ‘Why don’t I just give the house to my kid?’ that concerns me on many levels,” says Harriet Prensky, an attorney with a specialty in elder law. For one thing, it dumps the cost of your care on the taxpayers. “Do adult children have an entitlement to an inheritance at the cost of the taxpayers paying the bills for their parents?” asks Prensky. “Should the rest of us pay for their mother to be in a nursing home so they can inherit the house?”

It can also be a tragic personal mistake. “You may think your kid is going to take care of you for the rest of your life, and guess what? The kid gets divorced, the kid gets sued, the kid dies—or the kid doesn’t like you any more and wants you to be in a nursing home,” says Prensky. “That leaves you really vulnerable and without the funds that are necessary to pay for home care, to pay for assisted living.”

Seventy percent of people over 65 will require long-term care at some point—either in their own home, in an assisted living facility or in a nursing home. Medi-Cal pays only for care in nursing homes (which are also called skilled nursing facilities, or SNFs; those in the healthcare biz pronounce it “sniffs”). If you’re able to manage at home, but need help with personal grooming or other daily needs, you can hire a home health care aide from an agency for $20-$24 an hour. Low-income seniors may qualify for the county-run In-Home Support Services program and pay nothing. Just as with Medi-Cal, your home is an exempt asset. You can be living on Social Security in a million-dollar house with a view of the bay and still get free services from IHSS. For the many seniors in Marin who are house-rich and cash-broke, that can be a lifesaver.

Assisted living facilities—also known as board and care—are designed for those who need round-the-clock help, but don’t require the trained medical attention provided by a nursing home. Assisted living might cost $3,000-$5,000 a month, as opposed to $6,500 for a private pay patient in a SNF. There are also congregate care retirement communities—the most luxurious of options—that offer the full spectrum of living arrangements, from complete independence to skilled nursing.

If you’re not wealthy, however, the rent in an assisted living facility can quickly eat up your savings. If you’re in a nursing home as a private pay patient and you become destitute, Medi-Cal will take over payments for you. But there is no safety net for assisted living. “Once they spend down—say, they sold their house and they’ve been living in assisted living for X amount of years and they’re down to their last $5,000, they can be evicted,” says Sheila McGorty, the county ombudsman supervisor. “There’s no protection for them once they go on to SSI. We see people spend fortunes in these places and then they have to leave.”

Those patients are forced to move to other counties, far from their families. Outside of Marin, there are board and care providers that accept what a patient can pay out of her SSI check. The last of those places disappeared from Marin 20 years ago as property values skyrocketed.

BUT THE REAL estate boom has helped seniors lucky enough to own a home. The amount you can collect by renting your home, combined with your income, might be enough to pay for assisted living, or even a nursing home bed. Another option is to get a reverse mortgage. That’s a tax-free loan available to seniors age 62 and older who have little or no debt on their homes. Instead of making payments to the lender, the lender makes payments to you. You can either receive the loan in a lump sum, doled out in monthly increments or as a line of credit.

Terry Aman, reverse mortgage specialist at Bank of Marin, says that with property values continuing to soar, it’s hard to go wrong. Even if you run through your initial loan, you’ll still have plenty of equity left in the house. Aman points to one example of a reverse mortgage she arranged for two elderly women who own a home in Ross that’s valued at more than $1.5 million. They took their loan in a lump sum of $685,000. They’re using it to pay $11,000 a month for their in-home care and investing the rest. Other seniors use their loans for home improvements, or even for travel. The loan doesn’t have to be repaid until after your death. The disadvantage of a reverse mortgage is that it reduces the inheritance of your heirs.

Another possibility to consider is a life estate. You can sell your home at a reduced price with the agreement that you have the right to remain there for the rest of your life, and you use the cash from the sale of the house to pay for your in-home care. Some seniors have used life estates to shield their homes from Medi-Cal recovery. In this instance, rather than selling the house, you give it to an heir, retaining a life estate for yourself. Say you wind up spending three years in a nursing home and Medi-Cal covers your care at a cost of more than $100,000. If you had still owned your home, Medi-Cal would put a lien on it after your death to recover its costs. A life estate, on the other hand, terminates when you die. The state wouldn’t put a lien on a house you didn’t own.

At least, that’s been the case so far. California is one of the few states in the country that doesn’t make claims against life estates. But that stance is out of compliance with a federal law passed in 1993 that ordered states to go after life estates to recover health care outlays. Now, Governor Arnold Schwarzenegger has proposed new regulations that, among a number of other measures, declare open season on life estates. The regulations also would require repayment from family members who had been paid minimum wage to provide home care through IHSS.

Sarah Nome denies having given her home to her daughter in order to shield it from future liens. In her case, the lien is from Kaiser, not from the state. The hospital began charging her $3,200 a day for every day she occupied her room after receiving discharge papers in January 2004. She now owes over $1.3 million. Nome professes innocence. “I had no idea,” she says. “I’ve paid into Kaiser insurance ever since shortly after World War II. Every paycheck I got for 50 years, every medical deduction always went to Kaiser Hospital.” No longer. When I went to see her, Sarah asked me to hand her an unopened envelope in the pile of papers next to her bed. It was a letter from Kaiser Permanente, sent by certified mail, terminating her membership and transferring her medical care to Lafayette Convalescent Hospital.

Officials at Lafayette didn’t know what they were getting into when they accepted Nome as a patient. “We didn’t know her history,” says Ruby Abalos, Lafayette’s director of nursing. “If we had known, we would have had some questions.” Still, Abalos hasn’t found Nome to be difficult, aside from refusing to take her medications and not participating in any activities.

Nome, for her part, is not uncomfortable where she is. “It’s very pleasant over here, the people are very nice, they take very good care of me. However, I have only lived in Marin all my life.” She lived in a two-story gray house in a quiet neighborhood of well-maintained homes shaded by towering oaks. Nome’s yard is now overgrown with weeds. There’s a large crack in the front of the house where a tree fell on it, and one corner of the porch is crumbling. But if the house can be repaired, Nome hopes to live there again. “I have spent my entire life on Alder Avenue in San Anselmo,” she says. “That was my father’s home before me. My father and I have owned it for nearly 100 years. And I expect to die there.”

The county ombudsman program publishes a booklet, “Choices for Living,” listing all the licensed care facilities in Marin and their costs. For a free copy, call 415/499-7446.