Support for transition from care facility to community living
Contact Regina Martin, Program Coordinator Regional Lead, rmartin@putnamils.org or call 845-228-7457 (voice), 914-259-8036 (VP).
Open Doors is a specialized service to assist individuals living in a nursing home or Intermediate Care Facility in making decisions regarding home and community-based services. WILC’s Open Doors staff meets with individuals and their families to provide information regarding services and supports available in the community. The associated Peer Program consists of people who have lived in institutional settings, moved to home and community-based settings, and receive services and support where they live, who share their experiences with residents and support people who want to move to the community.
Through the Open Door Transition Center, program eligible individuals, their families and facility social workers receive information about available community-based programs and services, and assistance to make necessary program referrals. There is follow up with the person transitioning for a period of 12 months post transition. Eligible individuals may also apply for an Olmstead housing subsidy to assist them to secure an affordable and accessible apartment, as well as access to trained peer mentors who share personal experiences and offer support to those wanting to move back to the community.
Eligibility:
- Medicaid Eligible – must have Medicaid at least one day prior to discharge
- Transition specialists should utilize benefits advisors (or similar staff) at ILC to assist anyone who is interested in becoming Medicaid eligible. TS may continue to work with the individual to transition while Medicaid is being sought.
- Transition from qualifying institution ( i.e., hospital, rehab, skilled nursing facility or intermediate care facility)
- Must have been in the qualifying institution for at least 90 days at the time of discharge (This 90 days may be combined across settings. For example, in hospital for 30 days and in NH for 60 days would count. If person is using combined times for 90 days, make note in database with this information.)
- Must transition to a qualified setting (i.e., a home or apartment in the community owned or rented by the participant or their family members OR a group home with 4 or fewer unrelated individuals living together)
Services:
The Transition Center has trained Transition Specialists that help people living in nursing homes and intermediate care facilities to receive home and community-based services. This includes providing information about available services and supports where the person wants to live. There are Transition Specialists at independent living centers in counties all over New York State.
Transition Specialists assist in the creation of a plan to assist eligible individuals to successfully move into and remain in the community. Those services may include:
- Community preparedness education – information and education about skills necessary to live in the community
- Identifying and assisting in the application for specific services to meet a person’s individual needs
- Finding affordable, accessible housing to meet the individual’s needs
The Peer Program consists of people who have lived in institutional settings and then moved to home and community-based settings, and receive services and support where they live. Peers visit nursing homes and developmental centers to share their experiences with residents and support people who want to move to the community.
WILC is the regional lead agency for this program and our goal is to assist people living in nursing homes and OPWDD (Office for People with Developmental Disabilities) intermediate care facilities in the lower Hudson Valley Region to transition to and/or remain in the community. The lower Hudson Valley Region includes Westchester, Rockland, Putnam, Orange, Sullivan, Dutchess, and Ulster Counties and works with auxiliary outreach agencies based at local independent living centers throughout its catchment area.
