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

Rosalyn Briggs is a 69-year-old woman who had been living in the Plaza Rehab nursing home since 2019. She had multiple illnesses which unfortunately progressed to the point where she was admitted to a hospice care facility in February 2020 to be “comfortable in her final days.” As a result, her case was closed because her needs could not be met in the community.

Fast forward to August 2021. Rosalyn recovered in hospice care and was re-admitted to the nursing home. Her case was re-opened, paving the road to independence.

“My faith and willpower saved me by bringing me back to good health,” said Briggs.

Despite her desire and willpower to live on her own in the community Rosalyn was very hesitant due to the lack of informal support. Her family lives far away and could not always be there. She also struggled with anxiety about her memory when she was not able to recall certain information.

Transition Specialist Lisa Rivera with Bronx Independent Living Services connected Rosalyn to services so the transition into the community could begin. Lisa connected Rosalyn with the Olmstead Housing Subsidy (OHS) program. She got a Housing Specialist who worked on finding an apartment, along with guiding her through each step of the process to reduce anxiety.

For Briggs, 2022 was a very freeing year. Through OHS she was able to find an apartment and sign a lease in August. Lisa then helped her with the process of getting aide services in the community through a managed long term care plan. She also helped Rosalyn connect with the Good Neighbor Program to provide her with back-up supports and social connections in the community. Rosalyn’s Good Neighbor has already helped her navigate things like getting her social security in her name and getting meals delivered.

In October, after much planning, Rosalyn was finally able to move into her apartment with all the supports she needed. “I’m 1,000%...1,000,000,000% grateful to Lisa and the whole team for helping me get to where I am today. I am truly blessed,” said Briggs.