Money Follows the Person Transition Center

New York State's Money Follows the Person (MFP) program is part of federal and state initiatives to rebalance the state's long-term services and supports away from institutional care and toward integrated home and community-based care.

New York State's participation in the federal MFP program provides funding for the operation of a statewide Transition Center program, operationalized through a network of regionally based Transition Centers. Transition specialists provide transition assistance and other community transition support to eligible Medicaid recipients who are elderly or who are 18 years of age or older with a physical or developmental disability or a traumatic brain injury, and who want to transition from an institutional setting such as a nursing home or intermediate care facility to living and receiving services in communities of their choice. Transition specialists provide information about options for living and receiving services in the community and assist participants with planning transitions to the community. Transition specialists assist with resolving transition barriers and follow-up with participants for 365 days post transition to provide supplemental support and barrier resolution regarding access to home and community-based services and supports.

The intent of this Request for Applications (RFA) is to procure a single organization to administer a statewide Transition Center infrastructure which will provide the core activities of transition assistance, education and outreach, peer support, informal support, and ancillary transition support. The Transition Center will act as the New York State Department of Health's designated Local Contact Agency for the Minimum Data Set (MDS) Section Q referrals. Other Transition Center activities include targeted education and outreach to long-term care facilities on a biennial (every two years) regarding referral process, transition assistance, identification of potential referrals, availability of peer support and other Transition Center activities, as well as presentations to community-based organizations to encourage support and collaboration to support transitions.

The Grantee will administer a Transition Center project that provides informal support to MFP qualified individuals that transition from a long-term care facility for whom lack of an informal support network is a barrier to transition, with the goal of providing backup support, increasing community integration, developing a social network, and decreasing loneliness. In addition, the Grantee will provide ancillary transition support to meet identified needs during the five-year contract period.