By Ayse Akincigil and Uri Amir Koren

Many seniors in publicly subsidized housing need support services like chronic condition monitoring, medication management, and assistance with certain activities of living. Without such help, they risk premature nursing home placement. Assisted Living Facilities (ALFs) could meet their needs, but the aging population in New Jersey requires hundreds of new ALFs to keep up with demand. In an earlier blog, we introduced an innovative program that could meet their needs without having to build hundreds of new facilities, enabling the tenants to age in place.

This innovative approach, Assisted Living Program (ALP), de-couples the licensing of the support service provision from the licensing of the building. They deliver comparable levels of care within publicly subsidized housing, as the program is located within the housing complex rather than a dedicated facility, and partners with the property owners/managers.  Unlike ALFs, ALPs do not own or license the publicly supported housing building.

The census conducted by the Hub for Aging Collaboration at Rutgers, with the support of the New Jersey State Policy Lab, identified 370 subsidized low-income senior housing sites suitable for ALP operations. Meanwhile, only 18 of these housing properties are served by an ALP as of February 2024.  Such low market penetration for this promising model necessitates understanding the barriers to and the facilitators for its expansion. How do state policies, regulations, and practices impact economic sustainability of ALP providers?  With the support of the NJSPL, we are now conducting archival research and key informant interviews with individuals overseeing ALPs as well as non-profits involved with the ALP Coalition in New Jersey. We have included some of their insights in the quotes as follows.

Economic sustainability of home-based support organizations necessitates steady revenue stream. NJ Medicaid has the reputation to be one of the most innovative in the U.S. “New Jersey is the only state that has the ALP model in the books (i.e., Medicaid and Department of Health rules and regulations); …the steady revenue stream from NJ Medicaid supplemented by other grants made the current ALPs financially viable.”  Grant writing capacity within organizations was commonly mentioned as a facilitator for sustainability. It was also stressed that success requires substantial portion of income (approximately 75%) from steady streams.

“While the intentions (to support and expand ALP services) are there, the devil is in the details.” Key informants identified various policies that limit the expansion of the model. The first policy is the Asset Test Limits for Medicaid eligibility. Many tenants in the subsidized senior housing would have been eligible for receiving ALP services, due to their income and functional limitations. Yet, if they have any savings (i.e., assets) above $2,000, they will not qualify for Medicaid. One provider observed, “for fear of using up the small savings for an emergency or unexpected expense; tenants cannot be eligible for Medicaid and access our services.”

Another barrier was related to the licensing process. ALP providers encountered many challenges, particularly with regulatory interpretations and expectations during the licensure and survey processes. New Jersey code pools the rules and regulations of Assisted Living Residences (ALRs), ALPs, and congregate housing under one title. Regulations and compliance documentations include terminology and references that create uncertainty and ambiguity in determining what provisions apply to ALPs. “Survey and licensure compliance activities regularly treat ALPs as if they control the ‘facility’ when instead the building is controlled by the publicly subsidized housing owners or leasers… What we need is educating the stakeholders… to start with a pamphlet with two columns, comparing and contrasting ALPs and ALRs.” Misunderstanding the ALP model manifests in expectations that cannot be reasonably addressed when the scope of the organization is to provide services in a tenant’s home or apartment, without having any control over the facility.

Work is in progress to make changes in regulations. Advocates conducted a regulatory analysis, recommended revisions with priority regulatory citations for clarification, and regulatory oversight guidance. Asset limits have been in the forefront of Medicaid policy debates, since it affects not only ALPs, but access to all types of home and community-based services. For example, Medi-Cal (California Medicaid) eliminated asset limits in January 2024. New York adopted a similar strategy. Advocacy groups in NJ (e.g., Justice in Aging) are working to increase the asset limits to $40,000. This will enable increased access to ALP services and will make the model more sustainable.