Section Q of the Minimum Data Set (MDS) requires that nursing home residents are periodically assessed to determine the feasibility of, and interest in, discharge to the community. The assessments must be completed upon admission to the nursing home, annually, and whenever there is a significant change requiring a reassessment. If it is determined feasible, and the nursing home resident expressed interest in returning to the community, the nursing home will make a referral to the NYAIL Transition Center. Upon receiving a referral a local NYAIL Transition Specialist will meet with the individual in their nursing home to provide them with objective information about home and community based services. If appropriate for the program, the Transition Specialist (TS) will work with the person to help them transition back to the community.
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