Section Q of the Minimum Data Set (MDS) requires that nursing home residents are periodically assessed to determine 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 the nursing home resident expressed interest in returning to the community, the nursing home will make a referral to the Open Doors Transition Center. Upon receiving a referral, an Open Doors 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 Open Doors Referral Form. This form can be emailed or faxed to the Regional Lead Independent Living CenterRegional Lead Independent Living Center listed in your area. Referrals may also be sent to NYAIL via email to
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