Section Q Referrals

Section Q of the Minimum Data Set (MDS) requires that nursing home residents are periodically assessed to determine the feasibility of, and interest in, discharge to the community. The assessments must be completed upon admission to the nursing home, annually, and whenever there is a significant change requiring a reassessment. If it is determined feasible, and the nursing home resident expressed interest in returning to the community, the nursing home will make a referral to the NYAIL Transition Center. Upon receiving a referral, a local NYAIL Transition Specialist will meet with the individual in their nursing home to provide them with objective information about home and community based services. If appropriate for the program, the Transition Specialist (TS) will work with the person to help them transition back to the community.

Nursing Homes wishing to send Section Q referrals should use the referral form below. This form can be emailed or faxed to the Regional Lead Independent Living Center listed in the Section Q contact list below. Referrals may also be sent to NYAIL via email to This email address is being protected from spambots. You need JavaScript enabled to view it. or via fax to 518-465-4625.

Documents available for download:

Regional Lead and Auxiliary Primary Contacts and Counties

Open Doors Referral Form

Success Story

( Photo above of Miguel standing with walker, wearing T-shirt that reads "Wakanda Forever". )

Miguel Santana is a 63-year-old man who needed a hip replacement and after seven surgeries he was sent to the Bainbridge Rehab Nursing Home in 2020. Miguel’s case was assigned to Open Doors Transition Specialist (TS) Lisa Rivera with Bronx Independent Living Services (BILS) in October 2021. Miguel’s roommate at the nursing home successfully transitioned back to the community with the help of Open Doors and this TS. As a result, Miguel felt confident that he might be able to regain his freedom and independence and asked for an Open Doors referral to be made on his behalf.

When Lisa, the TS, discovered Miguel needed help managing his anxiety and depression due to the loss of his independence, she was able to connect him with Open Doors Peer Specialist Natalia Mendez. Natalia was instrumental in helping Miguel successfully deal with his experience at the nursing home, encouraging him to trust the process, and emphasizing the importance of embracing the progress he was making during his physical therapy sessions.

While Miguel was recovering in the nursing home, he lost his apartment and did not have a place to live when he was ready to return to the community. Lisa made an Olmstead Housing Subsidy (OHS) referral to connect him with a Housing Specialist (HS) and a rental subsidy. The HS, Irving McDonald, assessed his housing needs that would allow Miguel to live independently and safely in an apartment of his choice. The TS and HS were able to gather all the documentation that was needed for him to be eligible for the OHS program. This was no small feat as they had to find documents that had been lost while he was going from hospital to nursing home and back again.

Miguel was then pre-approved for a studio apartment and given an opportunity to see the space. He was worried because of the many surgeries he would not be ready to be discharged once the apartment was ready. Lisa and Irving assured Miguel that he should focus on recovery while they focused on the apartment, community supports and services that would be needed for a safe discharge.

Despite all the progress he made along the road to recovery, Miguel was still nervous about living on his own. The team (TS, Peer, and HS) supported him, and they all moved forward together which resulted in him signing the lease to his apartment!

Remember Miguel’s roommate from the nursing home? While looking at the studio apartment Miguel saw his good friend and former roommate. His apartment is in the same building and section as Miguel’s… just one floor above. “I was extremely surprised to see my friend from the nursing home in the same building. I was extremely happy and felt much better about living independently again,” said Miguel.

While Miguel has a supportive family, they do not live close by and are unable to help as much as he needs. Lisa made a Good Neighbor Program (GNP) referral. The GNP Manager was able to match Miguel with Good Neighbor Rudell Francis. Lisa also helped Miguel apply for home care, Access-a-Ride paratransit, and managing his Medicaid benefits.

In February 2023, Miguel was discharged from the nursing home and moved into his own apartment. “I couldn’t have done this without Lisa and the rest of my support system. They showed me that I can get back up and live on my own.”