A new training tool helps to assess whether some seniors can make informed choices about their own care and well-being.During a recent Zoom conference call, four Adult Protective Services workers from California, using a tool called the Interview for Decisional Abilities, or IDA, were trying to figure out whether something fishy was going on with an 82-year-old woman they knew as Ms. K.Adult Protective Services agencies in every state receive reports of possible neglect, self-neglect, abuse or exploitation of older people and other vulnerable adults. But agency workers consistently face a bedeviling question: Does the adult in question have the capacity to make a decision about their medical care, living conditions or finances — even if it’s not the decision that the family, doctor or financial adviser thinks should be made?IDA was developed by two geriatricians to help train Adult Protective Services workers in how to handle that issue. The program helps them learn to use a structured interview procedure to gather information about a client’s decision-making ability. The two dozen California staff members taking the course had already completed 10 hours of individual online instruction; now they were practicing their new interviewing skills in small groups, role-playing with facilitators.Ms. K, a fictional character, was being played by Bess White, a special projects administrator at Weill Cornell Medicine. In the scenario, a bank manager had reported certain suspicions: Ms. K had $60,000 in a savings account but her withdrawals had increased sharply, from $600 a month to $600 a week. A younger man — her nephew, she said — had begun accompanying her to the bank, where a teller thought the man had seemed controlling and intimidating. An investigator who visited Ms. K at home learned that her only credit card had expired and that she had little cash.But Ms. K denied being financially exploited; her nephew lived with her, she said, and helped with chores and rides to doctor’s appointments. He used the bank withdrawals to buy their groceries.In the exercise, one of the A.P.S. trainees had ascertained that Ms. K grasped the basic concept of financial exploitation. Ms. K had heard about scams from the news, she said. And yes, she understood that a friend or relative might similarly take advantage.So the interviewer continued: “What do you think could happen if someone took another person’s money without their permission?”Ms. White, in the role of Ms. K, replied: “I guess the person could take it and take it until there’s nothing left.” But when the interviewer probed further to see if Ms. K understood that she herself might be facing this risk, she balked. She relied on her nephew, Ms. K said; she didn’t want to upset him.IDA was developed by Dr. Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine, and his colleagues, and by Dr. Jason Karlawish, a geriatrician and co-director of the Penn Memory Center. “People have the right to make bad decisions,” Dr. Lachs said in an interview. But, he added, the decision makers must be able to understand the risks they face and the potential consequences.Dr. Jason Karlawish, left, and Dr. Mark Lachs, who helped develop the Interview for Decisional Abilities program, in a training video.Weill Cornell Medicine“How can you walk into a brokerage office at 90 years old and say, ‘I’ve had Treasury bills for 50 years but now I want to put my last $200,000 in Bitcoin’ — and nobody raises an eyebrow?” Dr. Lachs said. “We’re going to look back at this and say, ‘What were we thinking?’”Along with applying IDA to cases of financial neglect or abuse, the California A.P.S. workers were using it to assess a range of issues including self-neglect, health and safety questions, refusal of physical care or medical treatment, and physical or psychological or sexual abuse.“It’s not meant to replace a psychiatrist, but it tells you when to contact a psychiatrist,” Dr. Lachs said. Clients whose IDA interviews reveal an inability to grasp risks or consequences should receive a full professional assessment, he added.To date, about 500 A.P.S. workers — in New York City, Massachusetts and two California regions — have taken the course and received certification. Kansas A.P.S. workers will undergo training this summer.But Drs. Lachs and Karlawish think IDA could have broader uses. Trust and estate lawyers and financial firms are already asking them about it.Hospital discharge planners might use IDA to assess whether a patient has the capacity to insist on going home instead of to rehab. A chain of assisted-living facilities contacted Dr. Lachs, wondering if IDA could help ensure that new residents understood the complicated contracts they were signing.The IDA interview attempts to answer three fundamental questions about a particular problem or risk, Dr. Karlawish said: “Do you recognize that this happens? Do you think that this could be happening to you? Can you come up with a plan to address it, reasoning through and weighing the upsides and downsides?”Depending on a problem’s complexity, people with diagnosed cognitive impairment or even dementia may still possess sufficient understanding to handle it.Someone who demonstrates that three-part understanding during the IDA interview probably has the ability to make a decision — including a decision not to address the problem. Someone without that understanding needs a more comprehensive evaluation, perhaps including consultation with family members or social service agencies. In extreme cases, it might lead to eventual guardianship or conservatorship.Trouble handling finances often serves as an early warning of incapacity, said Dr. Daniel Marson, a neuropsychologist at the University of Alabama at Birmingham who has studied the subject for 25 years.“Financial capacity is probably the first higher-order functional ability affected by neurodegenerative disorders and by normal aging,” he said. Using money proficiently requires complex thought, from “something basic like using an A.T.M. to things that are more complicated, like ‘How should I handle this call from a telemarketer?’” The consequences of diminishing financial capacity — unsafe living conditions, impoverishment, homelessness, institutionalization — can be devastating.Although the incidence of dementia has been declining in the United States and Europe, the aging of these populations means that more individuals will develop it.Moreover, in a six-year study, Dr. Marson and colleagues found that older adults who were given a diagnosis of mild cognitive impairment — often a precursor condition to dementia — also struggled increasingly. “There were diminished financial skills over time,” he said.Other institutions have attempted to tackle the issue of diminishing decisional ability. The American Bar Association last year updated its “Assessment of Older Adults with Diminished Capacities: A Handbook for Lawyers.” The Bar Association and the American Psychological Association have also published handbooks for judges and psychologists.The Financial Industry Regulatory Authority, or FINRA, has posted online courses on financial exploitation of older adults and other vulnerable investors. Its rules allow a member firm to put a temporary hold on transactions and disbursements when it believes exploitation is involved. It also allows member firms to ask investors for a “trusted contact person” to consult in the event of suspected exploitation.The IDA program is focusing on A.P.S. workers for now because “the typical agency is understaffed, underresourced and struggling,” Dr. Karlawish said. California A.P.S. agencies handle about 30,000 cases involving seniors each month, according to state data, and “are being asked to make decisions about capacity that a chair of a psychiatry department might have difficulty with,” Dr. Lachs saidThe California staff on the Zoom training session, gently asking Ms. White — as Ms. K — how she might respond to the bank manager’s suspicions, eventually concluded that she did not need a professional work-up. It appeared that she understood her options.Giving her nephew access to her savings account might not have been the wisest move. But the decision was hers to make.

Through more than three decades of research, the Yale psychologist Becca Levy has demonstrated that age discrimination can take years off one’s life.Each fall, Becca Levy asks the students in her health and aging class at the Yale School of Public Health to picture an old person and share the first five words that come to mind. Don’t think too much, she tells them.She writes their responses on the board. These include admiring words like “wisdom” and “creative” and roles such as “grandmother.” But “‘senility’ comes up a lot,” Dr. Levy said recently, “and a lot of physical infirmity and decline: ‘stooped over,’ ‘sick,’ ‘decrepit.’”Dr. Robert N. Butler, a psychiatrist, gerontologist and founding director of the National Institute on Aging, coined the term “ageism” a half-century ago. It echoes “sexism” and “racism,” describing the stereotyping of and discrimination against older adults.Among the mementos in Dr. Levy’s small office at Yale is a treasured photo of her and Dr. Butler, who died in 2010. One could argue that she is his heir.A psychologist and epidemiologist, Dr. Levy has demonstrated — in more than 140 published articles over 30 years and in a new book, “Breaking the Age Code” — that ageism results in more than hurt feelings or even discriminatory behavior. It affects physical and cognitive health and well-being in measurable ways and can take years off one’s life.“Just as we have learned in recent decades that structures are biased against women and people of color, leading to worsened health outcomes, she has shown that negative feelings about old age lead to bad outcomes in older people,” said Dr. Louise Aronson, a geriatrician at the University of California, San Francisco, and author of the best-selling book “Elderhood.”Another memento in Dr. Levy’s office is a card on her bulletin board that reads, “Ask Me About 7.5.” The souvenir came from a Wisconsin anti-ageism campaign and refers to her 2002 longevity study, which for two decades followed hundreds of residents older than 50 in a small Ohio town. The study found that median survival was seven and a half years longer for those with the most positive beliefs about aging, compared with those having the most negative attitudes.“I use that in practically every talk I give because it’s shocking,” said Tracey Gendron, who chairs the gerontology department at Virginia Tech and credits Dr. Levy’s work in “Ageism Unmasked,” her own recent book. “She’s truly been a pioneer.”Dr. Levy and her team measure attitudes about aging in a variety of ways. They use questionnaires or the same five-word exercise she gives to her students. They test subliminal biases using computer programs that flash negative or positive words about aging so quickly that participants inadvertently absorb them. They have used small experimental samples of a few dozen people and tracked health records for thousands through big national surveys. Thanks to their efforts, we know that beyond reduced longevity, ageism is also associated with:Cardiovascular events, including heart failure, strokes and heart attacks. Using health records for almost 400 participants under 50 in the Baltimore Longitudinal Study of Aging, “we’ve been able to follow people for 40 years,” Dr. Levy said in an interview. “They had twice as high a risk if, at young ages, they’d taken in negative stereotypes about aging.” Their cardiovascular events occurred at earlier ages, too.Physical function. Among 100 older people (whose average age was 81), those exposed to implicit positive age stereotypes weekly for a month scored better on tests of gait, strength and balance than control groups did. In fact, those receiving positive exposure improved more than a similar-aged experimental group that exercised for six months. In a study of New Haven residents over 70, those with positive age beliefs were also more likely to recover fully from severe disability than those with negative beliefs.Alzheimer’s disease. Some participants in the Baltimore study underwent regular brain scans, and some donated their brains for autopsies. Those who held more negative age beliefs at younger ages exhibited a sharper decline in the volume of the hippocampus, the brain region associated with memory. They also exhibited, after their deaths, more of the brain plaques and tangles that are Alzheimer’s biomarkers.Another study used data from the national Health and Retirement Survey that included whether participants carried the APOE4 gene, which increases the risk of Alzheimer’s. Those with the gene who had positive age beliefs “had as low a risk as people without the gene,” Dr. Levy said.The list goes on. Older people with positive views of aging perform better on hearing tests and memory tasks. They are less likely to develop psychiatric illnesses like anxiety, depression, post-traumatic stress disorder and suicidal thoughts.In fact, Dr. Levy and her colleagues estimate that age discrimination, negative age stereotypes and negative self-perceptions of aging lead to $63 billion in excess annual spending on common health conditions like cardiovascular and respiratory disease, diabetes and injuries.Dr. Levy, who is 55, credits her focus on aging to an after-college job at a psychiatric hospital in suburban Boston, a graduate fellowship in Japan and an errant crate in a Florida grocery store.At the hospital, she worked in a unit for older patients and, to her surprise, enjoyed it. “It inspired me to want to understand the psychology of aging,” she said.Later, she planned to spend a semester in Japan, investigating why its residents have the world’s longest life spans. “I noticed how differently older people were treated there,” she said. “They were celebrated. Centenarians were rock stars!”Before leaving for Japan, though, she visited her grandmother, a lively septuagenarian. They were shopping together when Grandma Horty fell over a crate with jagged metal corners that had been left in the aisle.The resulting cut on her leg, though bloody, proved superficial. But when her grandmother suggested to the grocery owner that he not leave crates about, he responded that old people fall all the time, and maybe they shouldn’t be walking around.“The message stayed with her, and it seemed to impact her behavior,” Dr. Levy noticed. Her grandmother appeared to question her competence, asking Dr. Levy to take over chores she normally handled herself. The incident prompted Dr. Levy to contemplate how cultural values and people’s own ideas about age might affect them.We absorb these stereotypes from an early age, through disparaging media portrayals and fairy tales about wicked old witches. But institutions — employers, health care organizations, housing policies — express a similar prejudice, enforcing what is called “structural ageism,” Dr. Levy said. Reversing that will require sweeping changes — an “age liberation movement,” she added.But she has found reason for optimism: Damaging ideas about age can change. Using the same subliminal techniques that measure stereotypical attitudes, her team has been able to enhance a sense of competence and value among older people. Researchers in many other countries have replicated their results.“You can’t create beliefs, but you can activate them,” Dr. Levy said, by exposing people to words like “active” and “full of life,” instead of “grumpy” or “helpless,” to describe older adults.Could a society undertake such a mission? How long could the benefits of such interventions last? Would people need regular boosters to help associate aging with experience and possibilities instead of with nervous jokes?The research, by Dr. Levy and other scholars, continues.“Even though toddlers already have negative stereotypes about age, they’re not set in stone,” Dr. Levy said. “They’re malleable. We can shift them.”

Two neurologists argue that calling T.I.A.s what they are — minor strokes — could prompt patients to seek the help they need more quickly.On a recent afternoon in Bastrop, Texas, Janet Splawn was walking her dog, Petunia, a Pomeranian-Chihuahua mix. She said something to her grandson, who lives with her and had accompanied her on the stroll. But he couldn’t follow; her speech had suddenly become incoherent.“It was garbled, like mush,” Ms. Splawn recalled a few days later from a hospital in Austin. “But I got mad at him for not understanding. It was kind of an eerie feeling.”People don’t take chances when 87-year-olds develop alarming symptoms. Her grandson drove her to the nearest hospital emergency room, which then transferred her to a larger hospital for a neurology consultation.The diagnosis: a transient ischemic attack, or T.I.A.For decades, patients have been relieved to hear that phrase. The sudden onset of symptoms like weakness or numbness (often on one side), loss of vision (often in one eye) and trouble with language (speaking, understanding or both) — if resolved in a few minutes — is considered “transient.” Whew.But in a recent editorial in JAMA, two neurologists called for doctors and patients to abandon the term transient ischemic attack. It’s too reassuring, they argued, and too likely to lead someone with passing symptoms to wait until the next morning to call a doctor or let a week go by before arranging an appointment. That’s dangerous.Better, they said, to call a T.I.A. what it is: a stroke. More specifically, a minor ischemic stroke. (Almost 90 percent of strokes, which afflict 795,000 Americans a year, are ischemic, meaning they result from a clot that reduces blood flow to the brain.)Until recently, T.I.A.s “were played down,” said Dr. J. Donald Easton, a neurologist recently retired from the University of California, San Francisco, and an author of the editorial. “The person thinks, ‘Oh, it’s over. It goes away, so all is well.’ But all is not well. There’s trouble to come, and it’s coming soon.”The advent of brain imaging — first CT scans in the late 1970s, then the more precise M.R.I.s in the 1990s — has shown that many T.I.A.s, sometimes called ministrokes, cause visible and permanent brain damage.“Very quickly, nerve cells and their connections start to die,” Dr. Easton explained. And the risk of a subsequent stroke, possibly a more severe one, is highest within the first 24 to 48 hours.He and his co-author on the editorial, Dr. S. Claiborne Johnston, a neurologist at the University of Texas at Austin and former dean of its medical school, want people who experience these episodes to head for an emergency room, stat.“We’re trying to get rid of a term that has comforted people in the past,” Dr. Johnston said. Because “your brain is likely injured and you don’t want it to be injured further, you need to come in right away.”Dr. Jeffrey Saver, a stroke neurologist at U.C.L.A., called the proposed change in nomenclature “an intriguing, radical and potentially good idea.” The transient ischemic attack name dates to a 1975 report from the National Institutes of Health. So, he said, “this upends 50 years of classifying low-blood-flow events in the brain.”But will health care professionals change their terminology? “The T.I.A. concept is deeply entrenched in medical thinking,” Dr. Saver said. “It’s the kind of idea that will gather adherents slowly.”He supports the change, however, because “it reflects what we’ve learned over the last two decades — even very brief episodes of low blood flow to the brain lead to damage” and because calling such episodes “minor strokes” may lead patients to respond more quickly.“The treatments for ischemic stroke are very time-dependent,” he explained. “Every minute counts towards getting a better outcome.”In an emergency room or specialized stroke center, patients undergo a brain scan to be sure their symptoms resulted from a minor stroke rather than from a condition that can mimic it, like a seizure or a migraine.Patients who have suffered minor strokes usually start taking two drugs, typically aspirin and clopidogrel, which prevent clotting. (Some may need other medications or a surgical procedure, like a stent placement.)After three weeks, when the highest risk for another stroke has passed, most continue with just one drug, usually a low-dose aspirin. “It’s easy, it’s cheap and it’s well tolerated,” Dr. Johnston said.Twenty years ago, when Dr. Johnston led an early study of stroke risk after a T.I.A., 10.5 percent of patients suffered another stroke within three months; half of those occurred within the first two days.That rate has declined substantially, thanks to improved treatments for stroke, lower smoking rates and the widespread use of cholesterol and blood pressure drugs and blood thinners. Recent studies in The New England Journal of Medicine put the risk of a subsequent stroke, coronary syndrome or death after a T.I.A. at 6.4 percent in the first year and another 6.4 percent in years two through five.For neurologists, however, that is still high, given how devastating a major stroke can be. A name change for T.I.A.s might lead to quicker responses that further reduce the rate of subsequent stroke risk.Circumstances can arise when older people or their caregivers choose not to seek immediate medical help. In 2017, Maggie Flanagan was 88 and into her seventh year with Alzheimer’s disease when Therese Flanagan, her daughter and caregiver, suddenly noticed odd physical symptoms.“She was sitting in a recliner next to me when her head tilted back a little and her eyelids started to flutter,” Ms. Flanagan said. “One eye was drooping a little. I held her hand and said, ‘Are you OK?’ There was no response at all.” Then, a couple of minutes later, “she was back.”Before, when their mother was still able to make such decisions, she had signed a do-not-resuscitate order and an advance directive instructing that “she didn’t want her life prolonged,” her daughter said. The family agreed that taking her to a hospital would only cause fear and disorientation. She and her siblings decided not to call 911.Maggie Flanagan’s doctor said that she had probably experienced a T.I.A.; she had a more serious stroke five months later and died the following year, at home in her Chicago apartment.But most people choose treatment. Ms. Splawn, the dog owner from Texas, said she was feeling fine and expected to go home to Petunia shortly.Patients treated appropriately for minor strokes will remain at a higher-than-normal risk for another stroke, especially in the first year, Dr. Saver said. But “by two or three years out, the risk is just a little higher than for folks who never had a T.I.A. or a minor stroke.”Wanda Mercer, for example, had a minor stroke four years ago, at age 66. An administrator at the University of Texas, she had donated blood during her lunch break, then fainted in an Austin restaurant. The staff called 911, but in the emergency room, everything seemed normal; she went back to work and regaled co-workers with her noontime adventure.Suddenly, “I couldn’t find my words,” Dr. Mercer said. “I couldn’t articulate.” The problem lasted only seconds, but colleagues recognized a possible stroke and sent her back to the emergency room, where an M.R.I. revealed tissue damage. She has taken a statin, a cholesterol-lowering drug, and aspirin ever since.“I’m lucky,” she said. “I haven’t had one adverse symptom since.”

Health care researchers argue that hospice facilities could better serve some terminal patients, and ease the burden on exhausted loved ones.Where do people most want to be when they die? At home, they tell researchers — in familiar surroundings, in comfort, with the people they love.That wish has become more achievable. In 2017, according to an analysis in The New England Journal of Medicine, home surpassed the hospital as the most common place of death — 30.7 percent of deaths occurred at home, compared with 29.8 percent at the hospital.“It’s probably the first time that’s happened in the United States in modern times,” said Dr. Haider Warraich, a cardiologist at the Veterans Affairs Boston Healthcare System and an author of the study, published in 2019. Technically, the proportion was even higher, since some people who died in nursing facilities (20.8 percent) were long-term residents and the nursing home effectively was their home.Dr. Warraich credited the change to the rise of hospice care, for which Congress authorized Medicare coverage 40 years ago. By 2019, more than half of Medicare beneficiaries who died were enrolled in hospice. “There’s been a cultural shift,” he said. “People don’t want to die in hospitals, and hospice helps make that possible.”But not always.When Lee Zeiontz was dying of lung cancer, she wanted to remain in her apartment on the Lower East Side of Manhattan with her cat on her bed and her neighbors stopping by. Lynda Hollander, her niece, hired a round-the-clock aide to supplement the hospice staff.But Ms. Zeiontz’s pain eventually intensified and her older relatives were uneasy about administering morphine. “I think they were afraid of her dying at home,” said Ms. Hollander, a social worker in West Orange, N.J. They moved Ms. Zeiontz to an inpatient hospice unit at Mount Sinai Beth Israel Hospital, where she died a day and a half later, at 70.Similarly, Alan Mironer had vowed to care for his wife, Lynne, with hospice help in their home in Edina, Minn., as she died of breast cancer. “He felt it was his responsibility,” their son, Mark, said. But as she weakened and became unable to walk to the bathroom, he said, “suddenly, it was so much more work to take care of her.” The elder Mr. Mironer, then 81, became overwhelmed.Neighbors told them about a small hospice facility in Edina, with room for eight patients. Ms. Mironer spent her final week there, dying at 78.Such experiences prompted an article this month in The New England Journal of Medicine that pointedly asks, “Is There Really ‘No Place Like Home’?”The lead author, Dr. Melissa Wachterman, a palliative care specialist at Harvard Medical School, and her co-authors argue that alternative locations, including free-standing inpatient hospice facilities and hospice units within hospitals, could better care for some terminal patients with difficult symptoms and provide relief for exhausted families. They also contend that financial incentives play a role in where death occurs.“There’s a lot of cultural pressure: ‘If you really loved this person, you’d keep them at home,’” Dr. Wachterman said in an interview. “We need to acknowledge that there are people whose needs are so great that families cannot manage death at home.”Ninety-eight percent of hospice patients covered by Medicare receive what is called “routine home care.” The hospice organization sends nurses, aides, a social worker and a chaplain, in addition to drugs and equipment like a hospital bed, to the patient’s home. But it can’t provide 24-hour care; that falls to family or friends, or helpers paid out of pocket.Often, that’s sufficient. But death can follow unpredictable trajectories, and some terminal conditions appear better suited to home death than others. Cancer patients have the greatest odds of dying at home, Dr. Warraich’s analysis showed. Patients with dementia are most likely to die in a nursing home, and those with respiratory disease in a hospital.Some patients “may not need someone at the bedside 24 hours a day, but they need someone available 24 hours a day,” Dr. Wachterman said.A handful of hospice patients receive “continuous home care,” which means nurses and aides are provided eight to 24 hours a day; this accounts for 0.2 percent of hospice days, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare issues. Another handful receive inpatient services in a hospice facility, hospital or nursing home.But inpatient care is hard to secure, accounting for just 1.2 percent of all hospice days in 2019. To be covered under Medicare, the patient must be diagnosed with a symptom that cannot feasibly be managed in any other setting, and “that’s a pretty high bar,” Dr. Wachterman said.The authors also argue that although Medicare pays more for inpatient care — $1,000 a day, on average, compared with $200 for home care — profit margins are higher at home. More than 70 percent of hospices are now for-profit agencies.Rankings on the quality of hospital care like those published by U.S. News & World Report may also prompt hospitals, who want to keep their mortality statistics low, to discharge patients to home hospice.Edo Banach, president and chief executive of the National Hospice and Palliative Care Organization, disputed the article’s financial assertions. “It’s not true that margins are necessarily higher for routine home care versus inpatient,” he said, attributing profit differences to the length of a patient’s stay rather than the setting.Instead, Mr. Banach primarily blamed a fear of Medicare audits, which are not uncommon, for the infrequent use of inpatient hospice care. “Providers are very reluctant to use that benefit unless it’s also clear that they won’t be hurt by the government on the back end” and forced to return contested payments, he said.Still, he said there was nothing in the authors’ recommendations that he fundamentally disagreed with, including their calls for changes like financial support for family caregivers who assist dying patients.The authors also advocate expanded access to continuous home care and lower barriers to inpatient end-of-life care, in hospice facilities (the national organization estimates that about 30 percent of hospices have them) or hospice units within nursing homes and hospitals.Of the three times I have accompanied family members to their deaths, we achieved the good-death-at-home paradigm once: My mother died at 80, with uterine cancer and after a major stroke, in her own bed. My father and I cared for her, with a hospice team. He died at 90, when sepsis overwhelmed him in a hospital before I could arrange for hospice care at home.My sister’s death in 2015 showed the possibility of a middle ground. Disabled by late-onset Tay-Sachs disease, a neurological condition, she had been hospitalized with an uncertain prognosis. I was her health care proxy.As she declined, she developed such severe pain that, between sobs, she was calling for our long-dead parents. I immediately enrolled her in hospice and began planning to move her back to her assisted-living facility, so that she could die in her own apartment.It soon became clear that would be impossible. In the hospital, hospice nurses visited twice a day, constantly raising the dose of her morphine drip before switching to more potent medications. Having staff nurses always nearby allowed us to provide comfort, relying on a team we never could have duplicated on our own.To its credit, the hospital understood our needs. It arranged for a private room with 24-hour access for my cousin and me. We turned off the TV and the intercom, dimmed the lights, played soothing music, allowed family and friends to come and kept the vigil. It wasn’t homey, but it was peaceful. My sister, just 62, died after 24 days in the hospital and 14 in hospice care.Far more hospice patients and families could probably benefit from a similar option when home care proves too difficult.“For many patients, ‘home’ isn’t the physical place,” Dr. Warraich said. “It’s a metaphor for a place that’s not medicalized, that’s comfortable and full of love.”

The Program of All-Inclusive Care for the Elderly, funded by Medicare and Medicaid, has quietly succeeded in enabling some older Americans to age in place.Felicia Biteranta was struggling when, five years ago, she enrolled in a PACE program operated by Lutheran Senior Life in Jersey City, N.J.Having suffered a stroke, she found it hard to eat without choking. She fell frequently; her diabetes was out of control; she had pulmonary disease and asthma. She might miss a medical appointment if she could not arrange or afford a taxi. Her family lived far away.She was, in short, a candidate for a nursing home. But such a move is what PACE — the Program of All-Inclusive Care for the Elderly — was designed to prevent.“The main goal is to let people age in place,” said Maria Iavarone, executive director of the PACE program that Ms. Biteranta participates in. “Nobody wants to give up their home. It’s where you’re most comfortable. It’s where you should stay.”Ms. Biteranta now receives all of her health care through PACE, which monitors her, along with 120 other seniors, meticulously. PACE supplies much of her social life, too.“Here, they schedule you for appointments,” said Ms. Biteranta, 74, a retired nurse. “They send someone to take you and bring you home.”Carpal tunnel syndrome in her wrists and arms makes personal care and household chores difficult, so PACE sends an aide to her home 12 hours a week. “She cleans and does my laundry and the shopping,” Ms. Biteranta said. “She knows the food I like.”PACE provided the portable oxygen unit that freed her from dependence on the larger oxygen tanks she uses at home. It arranged cataract surgery and regularly ferries her to a podiatrist, a cardiologist, an endocrinologist and other specialists. It delivers a host of medications at no charge, including asthma inhalers and diabetes-testing supplies. A staff social worker helped her apply for and move into an apartment in a subsidized building for seniors.As a Medicaid beneficiary, she pays nothing for this care — no co-pays, deductibles or other out-of-pocket care expenses, and no caps on benefits. Should she require more home care hours or, eventually, a nursing home, PACE will cover those costs, too.“It’s worry-free,” said Ms. Biteranta, who was preparing to have lunch at the PACE Center as she spoke. “They worry for me.”Yet both the state and federal government also save money. PACE programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This includes doctors’ visits, tests, procedures, physical, occupational and speech therapy, social workers, home care, transportation, medication, dentistry and hearing aids. Participants typically visit a PACE center like the one in Jersey City several times a week for meals and social activities as well as therapy and health monitoring.That monthly payment is 15 percent lower, on average, than Medicaid would ordinarily pay to care for what are primarily low-income seniors, the National PACE Association said.Research has shown that PACE programs reduce hospitalization, emergency room visits and nursing home stays. Participants survive longer than similar patients in less comprehensive programs. A study last year by the federal Department of Health and Human Services noted that the PACE program “stands out from our analysis as a consistently ‘high performer.’”Why, then, do so few PACE programs exist — and enroll so few older Americans? Almost three decades after Medicare and Medicaid began funding PACE programs — today, there are 144, operating 272 centers in 30 states — the endeavor collectively serves fewer than 60,000 people, the National PACE Association reports.The association estimates that 1.6 million Medicare beneficiaries might meet PACE eligibility requirements. As a list of current programs shows, however, 21 states have no PACE program, and 11 have just one.Ms. Biteranta and her aide, Ms. Garcia-Reyes, on the way to lunch. Brian Fraser for The New York TimesProfessionals in elder care tend to be fans. “Every geriatrician loves this model,” said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine.Specialists like Dr. Lachs have complained for years that traditional Medicare will cover costly surgery to repair broken hips but won’t pay to install inexpensive grab bars that might prevent falls. With PACE’s fixed payments, “there might be less money, but you spend it the way you want to, without getting on the phone for insurance company approval,” Dr. Lachs said.At the ArchCare PACE program in New York City, for instance, “if a person’s air-conditioner breaks during a heat wave, we replace it,” said Walid Michelen, the program’s chief medical officer. “If there’s a snowstorm and they need food, we send it.”With coordinated care and close observation, “you head off a urinary tract infection before it becomes sepsis,” said Jay Luxenberg, the former chief medical officer of the On Lok PACE program in San Francisco. “Or pneumonia when it can still be treated by antibiotics, before you desperately need a hospital.”Yet growth has been slow. “We’ve had a lot of headwinds over the years,” said Shawn Bloom, the association’s chief executive.Persuading state legislators to expand PACE enrollment or authorize new programs has proved challenging; such moves represent new expenditures, even if they eventually reduce costs.For individuals, the enrollment process — which involves a state assessment to determine whether their medical conditions, cognitive status and functional limitations would warrant a nursing home — can take weeks. A family needing elder care immediately may be unable to wait.Moreover, agreeing to receive all health care from PACE often means relinquishing one’s individual doctor, and some patients balk at that demand. Programs can evade that barrier by allowing PACE programs to work with community physicians.But prospective patients may not know about PACE at all. “We’re trying to expand awareness, but we don’t have a ‘Got Milk?’ budget,” Mr. Bloom said.Still, the pandemic has intensified older Americans’ desire for alternative forms of long-term care. “If people didn’t want to be in nursing homes before Covid, they really don’t want to be there now,” Dr. Lachs said. According to the association, Covid deaths among PACE participants have been about one-third those of nursing home residents.So PACE’s growth is picking up, with 45 new programs expected to begin enrollment in the next two years, in part because of higher federal incentives. Moreover, for-profit companies are starting to establish or acquire PACE programs, although skeptics worry that for-profit status will lower quality.Several bills introduced in Congress would remove barriers to growth; one would build partnerships with Veterans Affairs hospitals to make PACE more accessible to veterans.Another intriguing possibility: Encouraging middle-class patients, for whom long-term care costs can also be ruinous, to enroll in PACE. Older adults who aren’t poor enough to qualify for Medicaid can already participate, but few do because their monthly premiums would be high — in many states, $4,000 to $5,000 a month.But that is still less than they would pay for nursing homes or assisted living in many locations. Policy analysts are looking into ways to reduce costs and expand PACE eligibility for the middle class.In Jersey City, Ms. Biteranta is doing well, although she misses concerts, Zumba classes, birthday parties and other events at the PACE center. Administrators curtailed such activities during the pandemic but hope to restore them as Covid rates decline.“Oh, my God, I’d be so depressed” without PACE, Ms. Biteranta said. “It gives me a life.”

Three recent developments — incremental and undramatic but encouraging — are likely to improve the lives and health of seniors.The Covid pandemic has presented older Americans with plenty of grim news, from staffing shortages in long-term care and hospices to the punishing effects of loneliness and isolation. But there have been encouraging developments too — the kind of incremental progress that can take years to achieve, as lawsuits wend their way through courts, bills die in state legislatures and rise again, and the pandemic complicates everything.The results are not always dramatic, but they can improve lives and health for older people, especially those with low income. Here are three.A New Right to Appeal Medicare DecisionsFirst, a federal appellate court recently ruled that if Medicare declines to pay for your rehabilitation in a nursing home after you’ve left the hospital, because you were “on observation,” you can appeal the decision.This issue has boggled patients and families for years. You were in a hospital bed, doctors and nurses provided care, you were examined and perhaps received medication, but you were not actually admitted. Or you were, and then the hospital changed your status to “on observation.” Technically you were an outpatient, not an inpatientBut Medicare requires three consecutive days as an inpatient for you to be eligible for nursing home coverage. So you are left either having to pay the tab yourself (the national average nursing home cost is $260 a day) or forgoing care. In fact, if you are among the 9 percent of Medicare beneficiaries who don’t have Part B, which covers outpatient care, you must pay the hospital bill, too.Hundreds of thousands of patients discharged from hospitals have probably faced this conundrum. “You can appeal just about every issue regarding your Medicare coverage, but not that one,” said Alice Bers, litigation director at the Center for Medicare Advocacy.To change this, the center — along with Justice in Aging and a private law firm — sued the federal Department of Health and Human Services in 2011.Last month, the U.S. Court of Appeals for the Second Circuit affirmed that Medicare beneficiaries have a constitutional right to appeal if hospitals reclassify them as observation patients. If patients win their appeals, traditional Medicare will pay for up to 100 days of nursing home care, and those who were previously forced to pay out-of-pocket could receive refunds. (Medicare Advantage plans don’t generally require the three-day stay.)The Center for Medicare Advocacy answers frequent questions here.One catch: The government could still ask the Supreme Court to take the case, or seek a rehearing by the Second Circuit court. And the Medicare appeals process is no picnic. “People have the best chance of winning if they persist and work their way up through the levels,” Ms. Bers said.Repealing the three-day requirement would take Congressional action. But at least with the right to appeal, you have a fighting chance.California Eases Medicaid QualificationsIn a second promising development, California is eliminating asset limits for older people who are trying to qualify for Medicaid, and other states are considering similar moves.Medicaid, the state and federal program that provides health care for the poor and for people with disabilities, and also pays for long-term care in nursing homes and at home, sets strict ceilings on recipients’ wealth. In most states, if you are older than 65, you can amass no more than $2,000 in assets, or $3,000 for a couple (usually with a home and a car exempted).“It makes people live in very deep poverty,” unable to save for emergencies or even modest expenditures, said Amber Christ, director of health care policy and advocacy for Justice in Aging. “If you go over the limit by a dollar, you lose eligibility.”California will abolish this ceiling in two steps. In July, the asset limit rises to $130,000 for an individual and another $65,000 for each family member. In July 2024, the state will discard asset limits altogether. If you are older or disabled, you will qualify for Medi-Cal (as California calls its Medicaid program) if your income does not exceed 138 percent of the federal poverty level. The state estimates that about 17,000 residents will become newly eligible.Gov. Kathy Hochul of New York has incorporated a similar measure in her proposed state budget, eliminating asset limits as of Jan. 1, 2023; the state legislature will tackle the budget in March. Arizona eliminated asset limits in 2001, although not for long-term care, and other states are looking into the approach, Ms. Christ said.One catch: This year, 138 percent of the federal poverty level amounts to an annual income of $17,774. Medi-Cal recipients must still be poor, but less poor than before, and will be better able to hold onto their health coverage.Social Security Offices to ReopenOffices closed since the beginning of the pandemic will reopen.Fred Prouser/ReutersIn a third piece of a good news, the Social Security Administration has finally announced that it will soon reopen its 1,200 local offices.Except for limited “dire need” appointments made at the discretion of managers, offices have remained closed since the pandemic hit in March of 2020. Now, said Mark Hinkle, a spokesman for the agency, “we anticipate that local field offices will restore increased in-person service to the public, without an appointment, in early April.”This matters. “There are things that have to be done in person for Social Security,” said Kate Lang, senior staff attorney at Justice in Aging. You can apply online for retirement benefits but not for survivors’ benefits or for Supplemental Security Income, or S.S.I., which helps support seniors with very low income.These in-person requirements have meant that hundreds of thousands of applicants who would normally walk into local Social Security offices, carrying the required original documents, have been out of luck for two years.Moreover, “people already on benefits have gotten notices saying their benefits are being reduced or discontinued, and they’re unable to get in touch with anyone at Social Security to find out what’s going on,” Ms. Lang said. “There’s no way to fix these problems.”Trying to reach Social Security by phone can be an exercise in frustration. A report from the agency’s inspector general found that monthly calls to field offices rose from 4.6 million before the pandemic to 7.5 million in April through September 2020, and to 12 million in March of 2021. If you called field offices or the national 1-800 number, you often encountered busy signals or long waits; many callers abandoned the effort.Even after the Social Security Administration agreed to reopen offices, protracted negotiations with its uneasy employees followed. But the agency and its unions have reached agreements, although they are still working out the logistics of reopening.One catch: Visitors to a field office will likely face occupancy limits, and the agency must cope with huge backlogs. In an email, Mr. Hinkle said that the agency encourages the public to use its online or phone services when possible and to schedule in-person appointments in advance.Ms. Lang noted: “It’s not like everything will be hunky dory on April 1.” In fact, Justice in Aging has brought a class-action suit against the Social Security Administration on behalf of S.S.I. recipients who were unable to provide information or challenge decisions while offices were shuttered.But, Mr. Hinkle said, offices will reopen this spring “dependent on the course of the pandemic” — indisputably a good thing.

Health experts are concerned that the pandemic, in upending daily routines, has reduced mobility and physical conditioning in older adults.In normal times, Cindy Myers, an executive at a nonprofit organization, is “not a real physical person,” she said. “I work at desk jobs. I’m not a big exerciser.”Still, before the pandemic, Dr. Myers, who is 64 and has a doctorate in organization development, commuted from her home in Petaluma, Calif., to an office in San Francisco. She met friends for lunch or coffee, and she went to restaurants, theaters and lectures with her wife. “There was so much more variety in my life, more locations, more people,” she said. “You’re not cognizant of all the moves you’re making.”Like many employees, Ms. Myers has now been working remotely for two years, curtailing social and cultural events and forgoing travel. That shift, perhaps exacerbated by a bout of depression in 2020, has taken a physical toll, she said. Her limbs feel weak, her balance rocky; she has fallen several times.“Basic kinds of movement you take for granted, like walking from one end of the house to the other, are exhausting,” she said. “I’m worried about it.”Many health experts are worried about worsening physical conditioning and mobility among older adults since Covid-19 upended the daily routine. Recent research indicates that many of those who had mild to moderate infections, even some who have managed to avoid the virus altogether, may be suffering functional declines.To date, much of the attention paid to the pandemic’s effects on the older population has focused on its frightful mortality rate: Nearly three-quarters of Americans who have died have been 65 or older.Researchers have also reported that, unsurprisingly, older adults whose Covid symptoms became serious enough to require hospitalization often contended with persistent physical and mental health problems.“When you’re hospitalized and you’re older, it takes a long time to get back on your feet,” said Marla Beauchamp, who researches mobility, aging and chronic disease at McMaster University in Hamilton, Ontario. “Covid is still impacting them in a significant way months and months later.”But less severe disease can also affect their physical ability. Dr. Beauchamp led a recent study of Canadians over 50 who had confirmed, probable or suspected Covid in 2020, when testing was not widely available. The study revealed worsened mobility among those with mild to moderate illness — 93 percent of whom were never hospitalized — compared with those without Covid.Nearly half of those 65 and older who had contracted Covid reported less ability to engage in physical activity like walking and exercising than before the pandemic — but so did about one-quarter of those who did not become infected. Smaller proportions of those uninfected said their ability to move around the house, and to do housework like dishwashing and dusting, had also declined.Although some of that decline might reflect normal aging, the study measured changes over only a nine-month period. In people who did not develop Covid, “the most plausible reason for the decline is public health restrictions during the pandemic,” Dr. Beauchamp said.Declines in physical function are showing up in older Americans, too. A University of Michigan team surveyed about 2,000 American adults aged 50 to 80 in early 2021, asking about their activity levels (but not about their Covid status).It found that almost 40 percent of those over 65 reported both reduced physical activity and less daily time spent on their feet since the start of the pandemic in March 2020. In this representative national sample, those factors were associated with worsened physical conditioning and mobility.“It’s a cascade of effects,” said Geoffrey Hoffman, a health-services researcher at the university’s School of Nursing and the lead author of the study. “You start with changes in activity levels. That results in worsened function. That in turn is associated with both falls and fear of falling.”Dr. Beauchamp added: “It’s really concerning to see this decrease in mobility. This is telling us that the pandemic alone has had a significant impact on older adults.”Neither of these observational studies, in Canada or in the United States, explored reasons for the self-reported increase in physical decline. But their authors suggested that pandemic-related restrictions could have caused deconditioning, even in people who were not ill.Not only did gyms, yoga studios, pools, adult day programs, community and senior centers all close for extended periods; many older people also undertook fewer ordinary chores and errands and may have skipped recreational pastimes.“If you’re limiting visits to the grocery store or having groceries delivered, or not going to visit or help with your grandchildren, if you’re not meeting friends at a coffee shop — those all take a certain level of physical activity,” Dr. Beauchamp said.Many older people did less traveling or in-person shopping; religious services, family gatherings and medical appointments moved online. “Picture how much activity we do without even thinking about it,” Dr. Hoffman said. When that changes substantially, “it adds up over six or nine months, then you have loss of balance or muscle strength, which leads to more trips and falls.”Disparities in health and income also appear to play a role, with reduced physical conditioning and mobility more commonly reported, in both countries, by respondents in low-income categories, in fair or poor health or with multiple chronic conditions.“Relatively healthy older adults have sufficient reserve if they reduce activity,” said Neil Alexander, a geriatrician at the University of Michigan and Ann Arbor Veterans Affairs who was not involved in the study. “High-risk people may be driving these numbers.”Dr. Alexander also pointed out that early in the pandemic, older patients had less access to rehabilitation and other services. “It was difficult to get people into the home for occupational therapy and physical therapy,” he said. “The support services to keep people mobile and functioning were disrupted.” Now, work force shortages may be having a similar effect, he noted.Physical function is key to living independently — the future that a great majority of older people envision for themselves. A loss of mobility and function across a considerable proportion of the senior population could mean increasing disability, a greater need for eventual long-term care, and higher Medicare and Medicaid costs.But that is not inevitable, Dr. Hoffman said: “You can reverse deconditioning. You can recover mobility.”Dr. Hoffman would like to see Medicare, which covers hip fracture surgery and rehabilitation after serious falls, underwrite extensive “pre-habilitation,” to rebuild the strength and balance of beneficiaries and prevent falls and fractures. He hoped that doctors conducting annual Medicare wellness visits would ask about fall risks and refer deconditioned patients to occupational and physical therapy.In the interim, individuals can resume walking, enroll in yoga or tai chi classes (outdoors, online, or seated in chairs, as needed), join fall-prevention programs, even practice getting in and out of chairs and lifting small weights on their own. (People should consult a doctor or physical therapist first if they have become severely deconditioned, however.)“You want to do everything you can to be as active and mobile as possible,” Dr. Beauchamp said.Dr. Myers, having found that “simply going about my daily routine isn’t enough to bring back my stamina and strength,” has a portable exercise bike set up in front of her television. She uses it, she said, but not often enough, a pattern she wants to change.“I need an intervention,” she said. “This isn’t the way I want to live.”

In a troubling picture, American women are looking at a rockier road to secure retirement than their male counterparts.Susan Hartt describes herself as an incorrigible optimist, drawn to change and challenge. After a long, successful career in marketing and public relations, she had reason to feel financially confident in her older years.But three years ago, a bank foreclosed on her modest house in Hamden, Conn. “I don’t think I’ve ever been as anxious in my life,” she recalled.Ms. Hartt, 79, had encountered a combination of adversities. After a late-life divorce she called “amicable and equitable,” she had no retirement plan; it had seemed unnecessary because her husband had a “substantial” 401(k). Successive jobs had grown less lucrative, and her freelance work dried up during the recession.Soon, temporarily living in an apartment owned by friends, she was selling off possessions — a collection of stained-glass lamps, first-edition books, her piano — partly to downsize, but also to raise money.A recent AARP survey found that almost 30 percent of women over age 65 reported feeling very or somewhat worried about their current financial situations (compared with 20 percent of men that age).Despite gains in education, employment and earnings in recent decades, American women still face a rockier road to secure retirement than men. Yet they live longer and are more apt to encounter illness, disability and the eventual need for expensive long-term care. It’s a troubling picture.“Women are considerably more likely to experience poverty in retirement than men,” said Richard Johnson, an economist at the Urban Institute in Washington, D.C.In 2020, according to Dr. Johnson’s analysis, 10 percent of women over 65 lived in poverty, compared with 8 percent of men, with far higher rates for women who were older, of color or unmarried. The poverty rate for unmarried Black women over 65, for instance, topped 20 percent.Even women who don’t sink below the federal poverty line — $12,413 last year for a one-person household — face economic precariousness. A quarter of working women over 55 are at risk of being among the working poor, defined as those who earn below two-thirds of the median hourly wage, or $15.29 an hour last year. Only 15 percent of men fell into that category, according to researchers at The New School in New York.Small wonder that a quarter of women over 65 consider an unexpected $1,000 expense “a major setback,” as the AARP survey showed.Anne Turley, 68, a veteran film and video editor, is getting by after some scary years of underemployment. She relies on about $1,200 in monthly Social Security benefits that she claimed early, at 62; a reverse mortgage on her house in Los Angeles; and the rent from a small studio in her backyard.But she recently needed a new hot-water heater and about $4,000 of dental work. “Every month is ‘How do I pay this?’ ‘How can I find money for that?’” she said.Economists attribute much of the retirement gender gap to “the motherhood penalty.” Women who raise children have fewer and lower-paid years in the work force than men or childless women, and “they never completely make up for the deficits,” said Matthew Rutledge, a research fellow at the Center for Retirement Research at Boston College.Social Security calculates benefits based on workers’ highest-earning years, he pointed out, and mothers are apt to have some zero-earning years that bring the average down, along with years of part-time work. Social Security offsets only part of the penalty.But much of the discrepancy in financial stability at older ages stems from a major demographic shift: Women now spend much less of their adulthoods in marriages.That is partly because women are increasingly marrying later, or not at all. But “gray divorces” — among people over 50 — doubled between 1990 and 2010, even as divorces declined in younger cohorts, said I-Fen Lin, a sociologist at Bowling Green State University in Ohio.Gray divorce now accounts for one in three U.S. divorces, Dr. Lin said. Although her research shows the rate holding steady, the number of divorced older people keeps growing as the population ages.Divorces in late middle age may improve women’s emotional well-being — they initiate them more often than men — but frequently devastate their financial health.Marriage combines incomes, reduces living costs and works “to smooth out the fluctuations, the job losses, the periods of disability, the years you took off to care for an elderly parent,” Dr. Rutledge said. “It’s almost like getting an insurance policy.”Losing that insurance takes a financial toll on women at any age, but after 50 “there’s less time to recoup,” Dr. Lin explained. “It’s hard to get back into the labor force, if you’re not working. And you don’t have as many years left to work and recover.” Moreover, older working women face both age and gender discrimination.Cynthia Palazzo, 61, spent most of her married years raising three sons in Akron, Ohio. When she and her husband started a manufacturing company, she was paid for her work there but never opened a retirement account, because “all our money was going back into the business.”When she divorced after nearly 30 years, Ms. Palazzo felt lucky to land a $17-an-hour job in medical billing and then, after being laid off in June, to quickly find another. With spousal support, “I’m OK now,” she said.But she bought a condo, and “it freaks me out that I’m going to have a mortgage until I’m 80,” she said. “I basically started life over at 54.”After gray divorce, women’s standard of living fell by 45 percent, Dr. Lin and her co-author found, while men’s decreased by just 21 percent. Repartnering, either through remarriage or cohabitation, helped divorced older women regain their financial footing, but only 22 percent of women repartnered, compared with 37 percent of men. (In Ms. Palazzo’s case: “Not going to happen.”)Changes in Social Security eligibility and benefits could reduce some of this inequity. The benefit for a divorced spouse, for instance, is half what a widowed spouse can claim. Caregiver credits could partially compensate for years spent in child rearing or elder care.“The basic rules were written in the 1930s,” Dr. Rutledge said. “They don’t recognize women’s increased employment. They don’t recognize that people don’t stay married for good.” Mandated retirement savings programs (Australia has one) would also help workers whose employers don’t offer them.It’s possible to see progress in these patterns. “It’s good news that women are working and living independently, emerging as independent economic actors,” said Teresa Ghilarducci, an economist at The New School, noting that younger women were narrowing the gender gap in earnings and savings.But many women currently approaching retirement may struggle, especially if they’re single like Ms. Hartt. She now lives frugally on a $2,500 monthly Social Security benefit. She drives a leaky 2001 Nissan she will be unable to replace when it dies. “Because I have no family and no savings, what worries me is if I were to become disabled, physically or mentally,” she said.One piece of luck: In September 2020, she moved into a cheerful apartment in a Section 8 subsidized housing complex in New Haven, for seniors and people with disabilities. The rent comes to $670 a month, including utilities.“I feel safe,” she said. “I’m at a kind of peace.” And because she hasn’t fully squelched her optimism, she buys a few lottery tickets each week.

Medicare has extended coverage of remote health care. While telehealth removed barriers to care for many during the pandemic, some say there is more to be done.Ben Forsyth had doubts about telehealth.When the coronavirus pandemic hit New York, he was wary of trekking by subway from Brooklyn to see his palliative care doctor at Mount Sinai Hospital in Manhattan. The prospect of entering a hospital and sitting in a waiting room troubled him, too.But when his doctor, Helen Fernandez, suggested a video visit to monitor his chronic kidney disease and other conditions, “I wasn’t sure how it would work,” said Dr. Forsyth, 87, a retired internist and university administrator. “Would I feel listened to? Would she be able to elicit information to help with my care?”Still, he logged on through Mount Sinai’s patient portal (“I wouldn’t say it was completely user-friendly”) on his laptop — and quickly became a convert.He’s had four video appointments with Dr. Fernandez since, along with two in-person visits once he was fully vaccinated. He consulted her remotely when he wintered in Florida; he has also seen his cardiologist and his sleep specialist through telehealth.Telehealth, also called telemedicine, refers to providing care remotely using technology such as video and phone calls, monitoring devices and patient portals.“It should be part of the options that people have,” said Dr. Forsyth.For now, it will be. In March 2020, Medicare greatly expanded coverage for telehealth, giving older Americans and others access to more health care options during the pandemic. Telehealth use promptly soared to nearly 52.7 million Medicare visits last year from 840,000 in 2019, according to a new federal report.Last month, Medicare announced that it would extend most telehealth coverage through 2023, to allow time to “evaluate whether the services should be permanently added” to its coverage. It had already made certain telehealth services permanent.This represents enormous change for telehealth. Before Covid, Medicare coverage for telehealth “simply wasn’t very available,” said Tricia Neuman, the executive director of the Program on Medicare Policy at Kaiser Family Foundation. Traditional Medicare permitted telehealth only in rural areas, for a narrow range of services. (Medicare Advantage plans had more flexibility.) Even then, patients had to travel to a clinic or hospital to do video calls if, for instance, they needed to consult with a specialist far away. They couldn’t receive telehealth at home, nor could they receive care over the phone.Doctors or physician assistants could provide telehealth and get reimbursed, but not physical therapists or nurse practitioners, and they had to have previously seen the patient in person.Then “the floodgates really opened at the beginning of the pandemic,” said Gretchen Jacobson, the vice president for Medicare at The Commonwealth Fund, which supports research to improve Medicare.Medicare removed the geographic barriers, so that patients across the country could receive telehealth in their homes.Jay Berger, left, a physical therapist, saw a patient from home in Frederick, Md.Dan Gross/The Frederick News-Post, via Associated PressOne hundred and forty additional remote services became eligible for coverage because of the move, as did more kinds of providers. Practitioners no longer needed a previous relationship with the patient and did not need to work in the same state as the person receiving care. If health care professionals lacked digital platforms that complied with federal privacy laws, Medicare allowed them to use widely available apps like FaceTime or Skype. It allowed coverage for audio-only phone visits, too.And it raised reimbursement amounts so that providers were not paid less for telehealth than for in-person visits, eliminating a critical disincentive.Now, it’s hard to imagine health care without the “tele-.” Nearly a quarter of U.S. adults over 65 have had a video visit during the pandemic, a Mount Sinai study found.“They’re most likely to need frequent medical care,” said Julia Frydman, the study’s lead author. Seniors also may face mobility problems that make office visits daunting, and with less effective immune systems, they’re at higher risk for Covid-19. Using telehealth, “they wouldn’t have to travel back and forth and be exposed to a deadly disease,” she said.Dr. Frydman discovered that another benefit of telehealth was learning more about her patients’ home environments. One older telehealth patient proudly told her about tending the greenery she noticed behind him. Then, over several months, she saw that his house plants were wilting and dying. “It prompted me to ask about his mood, his energy,” she said, and his answers revealed a previously unsuspected problem.In her palliative care practice at Mount Sinai, Dr. Frydman has found that of course, telehealth has limits. “You sometimes want to see patients walk into the room,” she said. “Has their gait changed? How do they get in and out of a chair?”That’s what soured Marcia Weiser, 83, on telehealth. “It’s better than nothing, but I don’t see that it’s optimal,” said Ms. Weiser, a retired calculus teacher on Manhattan’s Lower East Side. Many of her health issues, like joint pain and cholesterol monitoring, require “something hands-on, or a blood test or a urine test or an eye test,” she said. “I can’t get that on a computer.”While telehealth may not be for everyone, studies have shown that both patients and doctors broadly support it. After 2023, when the current Medicare extension ends, “the core question for policymakers will not be whether to allow telehealth, but how to make it efficient, effective and equitable, available to everyone,” said Dr. Jacobson.Researchers are still investigating whether patients using the virtual services fare as well as they do with in-person care, though one review of clinical trials using video teleconferencing found largely similar results.Analysts are also tracking whether video and phone visits replace in-person appointments or are additional, unnecessarily boosting Medicare spending. Whether telehealth is more prone to fraud than in-person care is unclear, too.Improving equity in telehealth poses another challenge, since access to digital devices and the internet varies significantly between different groups.JB Lockhart, 69, a self-described telehealth partisan in Lake Oswego, Ore., began video visits with her primary care doctor even before the pandemic. “I live on my computer,” she said.But a Kaiser Family Foundation survey in the fall of 2020 found that a quarter of Medicare beneficiaries over age 75 had no access to the internet. A little over half owned a computer or smartphone, a much lower proportion than among those 65 to 74.The Pew Research Center reported this year that over a third of adults over 65 never used video to talk to other people during the pandemic. Only 45 percent used a social media site. About a third lacked home broadband.Among the Medicare population last year, Black and rural beneficiaries used telehealth less often than whites and urban dwellers, the federal report showed. Dr. Frydman’s national study also noted geographic differences, and found that beneficiaries with lower education and those living alone also used telehealth less.“We need to be really careful that telemedicine doesn’t worsen health disparities,” said Dr. Frydman.Several recent federal initiatives will help make broadband more available. The largest appropriation, in the infrastructure bill President Biden signed last month, directs $65 billion to improve internet access in rural areas and tribal communities, and for low- income families.Along with improved internet access, older Americans may need coaching to use the technology, and web designers may need to make telehealth platforms simpler to use. An analysis of electronic health records at Mount Sinai, for instance, found that during New York City’s initial Covid surge, only 53 percent of patients in the geriatrics practice had activated their patient portal, which is necessary for telehealth via video.Health systems trying to reach older patients might heed Dr. Forsyth, who offered a marketing tip. “Telemedicine sounds so cold and technical,” he said. “If it were called an ‘electronic house call,’ people could feel more comfortable.”

The federal government recently lifted most visitation restrictions at nursing homes. But concerns linger that a full reopening could leave residents vulnerable to another coronavirus surge.For nearly 20 months, the roughly 1.3 million Americans living in nursing homes and their families grappled with strict visitation policies that, while designed to keep vulnerable residents safe from the coronavirus, caused distress for separated loved ones and had serious health consequences for many suddenly isolated seniors.Initially, visitors were barred entirely. Later, facilities enforced a variety of rules: Some prohibited visitors from residents’ rooms, allowed visitors only outdoors and during brief scheduled windows, or permitted only one at a time.Many of these restrictions were based on rules, known as “guidance,” mandated by the Centers for Medicare and Medicaid Services, the federal agency that closed facilities to visitors in March 2020. It has issued several revisions since.Now all that has changed. On Nov. 12, the federal agency removed virtually all such restrictions and advised the country’s nursing homes to allow visitation “for all residents at all times.” The agency noted that 86 percent of U.S. nursing home residents and 74 percent of employees were fully vaccinated, and that Covid-19 cases had fallen drastically.The update means no more limits on the frequency, time, duration, location or number of visitors. Access to residents’ rooms, unless a roommate is unvaccinated or immunocompromised, is allowed, and advance scheduling is not required.The federal policy still encouraged vaccination and emphasized infection control measures, including masks and distancing policies established by the Centers for Disease Control and Prevention.“It makes an important statement,” said Lori Smetanka, the executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group that had pushed for such change. Previously, “facilities were given a lot of discretion,” she said. “Whereas this is pretty clear: It puts rights back in residents’ hands.”While facilities can ask visitors about their vaccination status and encourage testing, they can’t require either vaccination or tests for entrance. Even during a Covid outbreak, under the new guidance nursing homes must allow visitors inside, albeit with masks. Visitors who decline to disclose whether they are vaccinated must also wear masks.The rules cover only nursing homes, which are federally regulated, but they may have a spillover effect. “I think many states will apply this to other settings, like assisted living,” Ms. Smetanka said. California, for instance, has already responded by loosening some assisted living rules.In nursing homes, with their frail and disabled residents, “there can be precautions, but cutting off residents from their families was unethical and it was bad care,” said David Grabowski, a health care researcher at Harvard Medical School. “These are not social visits.”With nursing homes short-staffed well before the pandemic, family visitors frequently helped feed, wash and dress their loved ones. They provided not only reassurance and stimulation, but also the ability to monitor the facility’s safety and quality. A study on which Dr. Grabowski was a co-author, for instance, showed that nursing home residents with dementia received better care at the end of life if a family member visited regularly.When the pandemic cut off such contact, for more than a year in many cases, families reported disturbing health declines. A study of Connecticut nursing home residents, for instance, found substantial increases in depression and unintended weight loss during the lockdown; incontinence increased and cognition declined.Gloria DeSoto, 92, met with family members through glass at the Hebrew Home last year.Seth Wenig/Associated PressTrish Huckin spent nearly a year battling administrators at her 96-year-old mother’s nursing home in Pinckney, Mich., before she was allowed inside to make so-called compassionate care visits. Even then, “the restrictions were ridiculous,” she said. The facility allowed her three one-hour visits a week in a public area, only by appointment. If she couldn’t make one of the prearranged times, she could not reschedule.When the facility finally eased restrictions, Ms. Huckin — with her wife, a hospital nurse — was finally able to see her mother, who has dementia, in her room. They discovered that in addition to losing weight and becoming depressed, her mother had developed a bedsore and early pneumonia.Claudia Hutchinson has also seen her sister, who resides at a facility outside Philadelphia, grow depressed and lose weight and mobility since her visits were restricted to an hour or less outdoors. “If we’d been allowed inside, she wouldn’t have had this downward spiral,” she said. “She wouldn’t be on hospice care.”Some doctors and families now worry that the pendulum has swung too far, that fully reopening will leave an already vulnerable population prey to another surge. Covid infections are rising in nursing homes; flu cases are up nationally as well.The day the new federal guidance was announced, a Connecticut nursing home reported the deaths of eight residents with serious underlying health issues from a late September outbreak.“To have people tromping in and out during an outbreak, we know that’s not a good idea,” said Dr. Karl Steinberg, a California geriatrician and the president of the Society for Post-Acute and Long-Term Care Medicine, which represents health care workers in long-term care.As a medical director or attending physician at three nursing homes, he saw the pandemic’s early toll: “It was a blood bath.” He wished the latest federal guidance had left administrators more flexibility. Medicare might also have waited until after the holidays, he noted, and until booster shots were more widely distributed.Despite the removal of federal restrictions, some administrators think state and local health regulations may supersede the new federal guidance, potentially blunting its impact.“The standard rule is that a facility has to follow the most restrictive rule,” said Dr. Noah Marco, the chief medical officer at the large Los Angeles Jewish Home. He is cautiously optimistic that in a few weeks the state and county will loosen their policies, too. But for now, the facility continues to require advance scheduling, limit visit length and permit each resident only one visitor at a time indoors.Since the new federal policy was announced, “our staff has constantly been on the phone,” Dr. Marco said. “We’ve had family members who’ve heard about this and are saying, ‘Yippee!’ We’ve had to say, ‘We’re so sorry, but not so fast.’”A representative for the Centers for Medicare and Medicaid Services said that state or local health departments might need to reinstate restrictions “due to severe safety reasons,” but only in “isolated situations.” The representative added, “local governments should generally not seek to add rules and regulations which limit a nursing home resident’s right to receive visitors.”The new federal policy — bolstered by the Biden administration’s mandate that all nursing home staff members be fully vaccinated by Jan. 4 — is likely to loosen more extreme local and state policies.Alison Hirschel, the managing attorney at the Michigan Elder Justice Initiative, has been advising a woman whose relative, in her 70s, suffered a brain injury after an accident and entered a nursing home a few months ago.“She was very distressed,” Ms. Hirschel said of the advisee, who lives out of state. “She had to drive seven hours for a visit, and the visit was limited to 15 minutes — and only on weekdays during business hours.”Then, a day after the liberalized federal policy was announced, Michigan issued new guidance that allowed visits at all times, with no limits on the length of the visit or the number of visitors. “This really is a complete game changer,” Ms. Hirschel said.