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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