Nursing Home Discharge & Transition Support

The Syracuse Region Open Doors Transition Center at ARISE, serves nine counties (Cayuga, Onondaga, Oswego, Madison, Jefferson, Herkimer, Lewis, Oneida, and St. Lawrence), directly assists residents in nursing homes and intermediate care facilities (ICFs/IIDs) expressing the desire to be discharged and live independently in the community.

How does the program work?

  1. Download, complete and submit a referral to the Open Doors Transition Center (see link to the right), which can be faxed directly to Juanita Clark-Abolafia at 315-510-4181.
  2. A Transition Specialist (TS) will be assigned to meet with the resident, social worker, family member and/or guardian to discuss specific care needs, explain how to access appropriate Home and Community-Based Services (HCBS) and any other necessary community resources to determine the safest option(s) for discharge and transition.
  3. The Transition Specialist will submit referrals to appropriate Home and Community-Based Services (HCBS) and any other necessary community resources, for evaluation.

What can I expect during the visit from the Open Doors Transition Specialist?

During the visit, we will speak to residents, families, and/or legal guardians about available home and community-based services and provide objective information for possible alternatives to remaining in a nursing home. Some examples of services include:

Home Care Services

  • Consumer Directed Personal Assistance Program (CDPAP)
  • Managed Long Term Care (MLTCs)

Housing Related Services

  • Olmstead Housing Subsidy (OHS)
  • Rapid Transition Housing (RTH)

Medicaid Waivers

  • Nursing Home Transition & Diversion (NHTD) Waiver
  • Traumatic Brain Injury (TBI) Waiver
  • Office for People w/Developmental Disabilities (OPWDD)

Mental Health Services

  • Health Homes Program

 

If you have any questions, feel free to contact us to learn more!

Open Doors Transition Center Program from NYAIL on Vimeo.