Transition Center

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. The Transition Center is staffed by a Project Director, a Statewide Transition Specialist, two part-time Registered Nurses (RNs) and a Social Worker. NYAIL works with 9 Regional Lead ILCs and 14 Auxiliary Independent Living Centers (ILCs) -- see below for a list of these ILCs. 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, and 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) and the Traumatic Brain Injury (TBI) Waivers 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 will be actively assisting individuals with developmental disabilities in moving from developmental centers (DCs), Intermediate Care Facilities (ICFs), and nursing homes into private homes, apartments, or community residential settings. Some individuals will move out of ICFs and DCs, while others may remain living in their current location, but will experience greater community integration as ICFs (which follow an institutional program model) convert to Individual Residential Alternatives (IRAs). Transition Specialists will meet with these individuals and/or their family members/advocates. The TS can assist with selecting a Medicaid Service Coordinator (MSC) 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 NYAIL's Transition Center Hotline at 844-545-7108, via fax to 518-465-4625, or via email to This email address is being protected from spambots. You need JavaScript enabled to view it. .

For more information:

Suzanne de Beaumont
Project Director
MFP Transition Center
155 Washington Ave, Suite 208
Albany, New York 12210
Phone: (844) 545-7108

Documents available for download:

Open Doors Referral Form

Regional Lead and Aux Chart

Open Doors (MFP) Transition Center Regional Contacts
Regional Counties	Contact Information	Auxiliary Independent Living Centers
Albany North Clinton, Essex, Franklin, Fulton, Hamilton, Montgomery, Saratoga, Warren, Washington	Dr. James Swanson Director of Advocacy and Transitions Southern Adirondack Independent Living Center (SAIL) 71 Glenwood Ave Queensbury, NY 12804 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 518-792-3537 ext, 1135 Kathryn Been Senior Open Doors/MFP Transition Specialist (518) 792-3537 ext. 1322 (518) 333-2218 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Fax: 518-792-0979	North Country Center for Independence, Plattsburgh Lynden Davies: 518-563-9058
Albany South Albany, Columbia, Greene, Rensselaer, Schenectady, Schoharie	Debbie Abreu Independent Living Center of the Hudson Valley (ILCHV) 15-17 Third Street Troy, NY 12180 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 518-274-0701 x 108 Fax: 518-274-7944	Capital District Center for Independence, Albany Stacey Porter:518-459-6422
Buffalo Cattaraugus, Chautauqua, Erie, Niagara, Orleans, Wyoming	Gerilyn Capps-Anderson Western New York Independent Living (WNYIL) 3108 Main Street Buffalo, NY 14214 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 716-284-4131 Fax: 716-284-3230	Southwestern Independent Living Center, Jamestown David Marg: 716-661-3010 WNYIL, Batavia Naomi Godlove: 585-815-8501 x 410
Long Island Nassau, Suffolk	Michelle Darling- Downs/ Eileen Thomas Suffolk Independent Living Organization (SILO) 755 Waverly Ave. Holtsville, NY 11742 Email: This email address is being protected from spambots. You need JavaScript enabled to view it., This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: (631) 880-7929 x 105 Fax: (631) 946-6377
Lower Hudson Valley Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester	Tracy Marcus Putnam Independent Living Services (PILS) (A Satellite Office of Westchester Independent Living Center, Inc.) 1441 Route 22, Suite 240 Brewster, NY 10509 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 845-228-7457 x 1129 Fax: 845-228-7460	Resource Center for Accessible Living, Kingston Chris Al-Nazer: 845-331-0541 x 12 Rockland Independent Living Ctr., New City LaTerra McGee 845-624-1366 Taconic Resources for Independence, Poughkeepsie Kathy Sheehan: 845-452-3913 Westchester Disabled on the Move, Yonkers Yaw Appiadu: 914-968-4717
New York City Bronx, Kings, New York, Queens, Richmond	Dheki Dolma Lama Center for Independence of the Disabled in New York (CIDNY) 80-02 Kew Gardens Road Kew Gardens, NY 11415 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 646-368-8034 Fax: 347-561-4883	Brooklyn Center for Independence of the Disabled, Brooklyn Yvette Wilson: 718-998-3000 Bronx Independent Living Services, Bronx Deja Jones: 718-515-2800 Staten Island Center for Independent Living Rita Caputo 718-720-9016
Rochester Genesee, Livingston, Monroe, Ontario, Seneca, Wayne, Yates	Susan Stahl Center for Disability Rights (CDR) 497 State Street Rochester, NY 14608 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 585-546-7510 Fax: 585-546-7542
Southern Tier Allegany, Broome, Cayuga, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Steuben, Tioga, Tompkins	Krystal Pierre- Millien Southern Tier Independence Center (STIC) 135 East Frederick St. Binghamton, NY 13904 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 607-724-2111 Fax: 607-772-3606	AIM Independent Living Center, Corning Sara Rockwell-Smith: 607-962-8225 Access to Independence, Cortland Anne Marie Piche, Terri Rigge: 607-753-7363 Catskill Center for Independence, Oneonta Heather Merrill: 607-432-8000
Syracuse Madison, Onondaga, Oswego, Herkimer, Lewis, Oneida, St. Lawrence, Jefferson	Juanita Clark-Abolafia ARISE Independent Living Center 635 James Street Syracuse,NY13203 Email: This email address is being protected from spambots. You need JavaScript enabled to view it. Tel: 315-671-2948 Fax: 315-671-2977	Massena Independent Living Center, Massena Tina Laflesh: 315-764-9442 Resource Center for Independent Living, Utica Maxine Nasby: 315-797-4642

Resources

Open Doors Transition Center resources are available below. Transition Specialists may access additional resources through the Open Doors Database.

Program Materials

DOH Informed Consent Form

OPWDD Informed Consent Form

Dear Administrator Letter

Open Doors Transition Center from NYAIL on Vimeo.

For more information:

Suzanne de Beaumont
Project Director
MFP Transition Center
155 Washington Ave, Suite 208
Albany, New York 12210
Phone: (844) 545-7108

Documents available for download:

Open Doors Referral Form

Regional Lead and Auxiliary Primary Contacts and Counties

Success Story

Milton

In 2015, Milton Diaz Galarza was sent to a nursing home in New Jersey when his needs could no longer be met in the New York nursing home where he had resided since November 2014. He was only 53 years old at the time. While at Andover Subacute and Rehab in NJ, Milton received treatment and improved considerably. Milton is a New York resident and indicated that he wanted to return to New York City. As a result, Milton was referred to the Open Doors Transition Center in 2017. The Transition Specialist from Open Doors worked closely with the NJ Nursing Home staff to resolve barriers to fulfilling Milton’s wish to return to the community. Milton had long since lost his apartment and was unable to locate housing on his own. The NJ nursing home staff were willing to help Milton but needed assistance with the complex NYC systems. The Transition Specialist had to find a creative way to apply for services that required a New York address.

On November 5, 2018, Milton successfully transitioned into a supportive housing residence through Transitional Services for New York, Inc. (TSINY). Milton is now able to enjoy more freedom since he returned to the community. He has been enjoying getting to know the area and other individuals in his building. He is excited to start group programs where he will learn and further develop his independent skills such as cooking his own meals. Milton’s goal is to someday soon move into his own apartment.