The New York Association on Independent Living (NYAIL) Open Doors Transition Center is focused on assisting people living in nursing homes and intermediate care facilities to receive individualized home and community based services. This includes providing people with objective information about services and supports that are available in their local community. NYAIL was selected by the Department of Health to coordinate the Open Doors Transition Center Project as part of State's Money Follows the Person (MFP) program.
The Open Doors Transition Center assists people in nursing homes who wish to return to the community. NYAIL works with Independent Living Centers (ILCs) across the state to provide locally based transition assistance. These ILCs employ Transition Specialists (TS) who are familiar with the services available in the local community. These staff will meet with individuals residing in nursing homes and/or their family members. For individuals in nursing homes, the TS will identify what is needed for the person to return to the community and will assist in getting those needs met. For example, a common barrier to returning to community living is lack of housing. It is difficult for a resident in a nursing home to locate housing that meets their physical needs, that is affordable and available. The TS can search for housing via housing databases, as well as use their personal knowledge of local assets such as senior housing programs. If needed, the TS can then access environmental modification programs to ensure the home is accessible for the individual. The TS can also assist with accessing housing subsidies if the rent exceeds the individual's budget. Additionally, the TS can provide community preparedness education to ensure that individuals have the information/skills they will need immediately upon return to the community. The TS role and process is tailored to the specific needs and desires of each individual and is designed to make the transition happen in the smoothest and quickest way possible. The Transition Center works closely with the Nursing Home Transition and Diversion (NHTD) waiver, the Traumatic Brain Injury (TBI) waiver, Managed Long Term Care plans (MLTCs) and other programs to provide services that will support people in the community.
The Open Doors Transition Center also works closely with the Office for People with Developmental Disabilities (OPWDD). OPWDD actively assists individuals with developmental disabilities in moving from Intermediate Care Facilities (ICFs) and nursing homes into private homes, apartments or community residential settings. Transition Specialists will meet with these individuals and/or their family members/advocates. The TS can assist with selecting a Care Manager(CM) who will best meet the individual's needs. The TS can assist and ensure that the individual has the skills and supports he/she needs to be ready for the community. The TS will also participate with the treatment team in creating a person-centered plan that promotes independence and meaningful community involvement.
Anyone can make a referral to the Open Doors Transition Center. The Transition Center Referral Form (available for download below) can be completed and sent to the Regional Contact listed in the chart below. Referrals can also be made by calling Open Doors' Transition Center Hotline at 844-545-7108, via fax to 518-465-4625, or via email to
For more information:
Suzanne de Beaumont
Project Director
Open Doors MFP Transition Center
155 Washington Ave, Suite 208
Albany, New York 12210
Phone: (844) 545-7108
Documents available for download:
Regional Lead and Auxiliary ContactsRegional Lead and Auxiliary Contacts