The Open Doors Transition Center consists of a network of 24 local transition centers throughout New York State. Working with nursing home and intermediate care facility staff, and home and community-based services providers, transition specialists assist participants to identify and access supports, benefits, and services in the community. Open Doors serves as a bridge between facility discharge planning and coordination and delivery of medical and supportive services in the community.

Peers are people who have lived in institutional settings and then moved to home and community-based settings, and who have received services and support where they live. Peers visit and talk to Open Doors participants in nursing homes and intermediate care facilities to share their life experiences living independently in the community. Peers provide support during the transition process and can assist with community integration. Peers who are military veterans and family peers are also available to offer support. Peer support is available during the transition process and up to 60 days after discharge.

Education and outreach staff provide targeted education to all nursing homes throughout New York State regarding the Minimum Data Set Section Q, the referral process to the Local Contact Agency, and the availability of community supports. These presentations include helpful information on transition center referral, assistance, and collaboration, and how these activities support compliance with the Olmstead decision. Presentations about Open Doors are also provided to many other referral sources such as community-based service providers, Ombuds staff, managed care plan staff, and others.

The Good Neighbor project helps participants who do not have informal supports such as family and friends to support them in the community after they leave a nursing home or intermediate care facility. Good Neighbors can help fill crucial gaps in participants' informal support networks to enable participants to move from the facility to the community.

To support participation in the transition planning process, participants may be able to receive an Open Doors mobile phone with pre-paid minutes and a short-term data plan to help them communicate with their transition specialist, community service providers, and informal supports during the transition planning process.

The federal Home and Community Based Services Final Rule supports participants to have full access to the benefits of community living and receive services in the most integrated settings. Person-centered planning coaching teaches Open Doors participants skills to improve self-advocacy during the person-centered planning process. This service is offered post-discharge to individuals who have transitioned to and are receiving services in the community.

Grocery cards are available to participants identified as being at risk for food insecurity during the first month after discharge from the facility as a bridge to more permanent solutions.