The Open Doors Transition Center Project/Peer Outreach and Referral Program identifies and reaches out to nursing-home residents who are Medicaid recipients, who want to explore transitioning back into the community. 

Open Doors provides comprehensive and unbiased information about home- and community-based services.

Contact with nursing-home residents and/or their legal representatives is conducted by peers, including seniors and people with disabilities. 

Nursing-home residents and legal representatives who have not been identified by project criteria can request to meet with Open Doors transition specialists. Additionally, family members and professional staff may make referrals.

Open Doors staff will inform facility discharge planners of a resident’s desire to return to the community when requested to do so by the resident or the resident’s legal representatives.

Once equipped with information, residents and/or their legal representatives can work with discharge planners to arrange a transition back into the community with appropriate services.

Open Doors transition specialists can assist discharge planners in locating community services for their residents.

For more information, contact Sara Rockwell-Smith.

Open Doors is a statewide program administered by the New York Association on Independent Living. It is funded by Money Follows the Person, a federal program.