NYS Money Follows the Person Demonstration (MFP)

Money Follows the Person (MFP) is a Medicaid program sponsored by the Centers for Medicare and Medicaid Services and the New York State Department of Health. The MFP program does not provide money directly to individuals.

MFP funds the Open Doors program. Open Doors assists individuals living in nursing homes and intermediate care facilities who express a desire to explore options for living and receiving services in the community.

Open Doors Transition Centers

Open Doors consists of a network of 24 Transition Centers, located within Independent Living Centers throughout New York State. Working with Nursing Home and Intermediate Care Facility staff, managed care plans, Home and Community-Based Services (HCBS) waivers, Health Homes and community service providers, transition specialists assist participants with identifying and accessing needed supports, benefits, and services in the community. Open Doors serves as a bridge between pre-discharge planning and coordination in the facility and the delivery of medical and supportive services in the community.

Open Doors also offers peer support. Peers are people who live independent lives in the community. By sharing their life experiences in transitioning from facilities to the community, peers provide support during the transition process and can assist with community integration. Family members of individuals who have previously transitioned are also available to meet with the families of transitioning individuals. Veteran peers are available as well.

For more information about MFP and Open Doors, view this 2017 webcast: The Money Follows the Person Program: Facilitating Return to Community-based Settings.

View a video about Open Doors here.

Open Doors as the Local Contact Agency

Open Doors is the designated Local Contact Agency for Minimum Data Set (MDS) Section Q referrals in New York State. The MDS is part of the federally mandated process for assessing individuals receiving care in certified skilled nursing facilities. Section Q is a series of questions in the MDS that asks nursing home residents if they would like to explore options for living and receiving services in the community.

In October 2019, sections 415.2 (Definitions) and 415.3 (Resident´s Rights) of Title 10 NYCRR, New York State Nursing Home Regulations, were amended to require nursing homes to provide residents with information about home and community-based services and transition programs that can support individuals´ return to the community. Included in the regulation is the requirement to refer to the Local Contact Agency.

Education and outreach staff provide targeted education to all nursing facilities throughout New York State regarding MDS Section Q and the referral process to the Local Contact Agency. These presentations include helpful information for nursing home staff on Transition Center referral, assistance, and collaboration, and how these activities support compliance with the Olmstead decision.

For more information about the Minimum Data Set, Section Q and Open Doors as the Local Contact Agency, view this 2019 webcast: Discussing Return to Community Living: Best Practices for MDS Section Q.

Adults age 18 years or older who have:

  • ✓ Medicaid coverage for at least one day before transition
  • ✓ Lived in a nursing home, hospital, or intermediate care facility for at least 60 days
  • ✓ Needs that can be met in the community with home and community-based services
  • ✓ Moved to a community home, such as a house, apartment, or small group home providing residence for four people or less
  • ✓ A physical or developmental disability, traumatic brain injury, or who are elderly (including those elderly with mental health needs)
  • ✓ Consented to participate

Open Doors Transition Center:

Open Doors Education and Outreach:

  • To schedule an educational presentation, contact Open Doors toll-free at: 1-844-545-7108 or by e-mail at: secq@ilny.org

New York State MFP Program:

An important role of MFP is making sure that people have the chance to express their opinions and feelings about the services they receive, and their impact. To this end, participants are asked to take part in a Quality of Life survey prior to facility discharge and again after 11 months. MFP´s Quality of Life survey measures satisfaction in several areas, including:

  • Living situation
  • Choice and control
  • Community inclusion
  • Overall life satisfaction

The surveys are confidential and voluntary. The results help to evaluate the MFP program. Survey results have consistently shown an improved quality of life for participants after moving to the community. To view selected Quality of Life survey results, view our Money Follows the Person: At-a-Glance.

Publications related to the national evaluation of MFP:

  • Technology-Related Assistance for Individuals with Disabilities (TRAID) Program:
    • ➤ Twelve Regional TRAID Centers offer local assistive technology-related information and referral, product demonstrations, device loans and advocacy and awareness services. TRAID staff are knowledgeable about the policies and procedures of available programs and funding sources for assistive technology.
    • Justice Center TRAID Centers (including contact information)
  • Person-Centered Planning Comprehensive System Transformation Statewide Training Initiative:
  • Community Care Connections:
    • ➤ Lifespan's mission is to provide information, guidance, and services that help older adults take on both the challenges and opportunities of longer life in a community setting. The Community Care Connections project evaluated and informed effective approaches to integrating community-based aging services with medical systems of care.
    • Lifespan of Greater Rochester, Inc.
    • ➤ Community Care Connections Final Report - (Web) - (PDF)
    • ➤ Community Care Connections Final Report Presentation - (PDF)
  • New York State Caregiver Guide
    • ➤ A useful guide that provides tips and strategies, as well as legal and medical definitions, resources, and information about rights, to assist seniors and their caregivers as they age in place.
    • NYS Caregiver Order Request Form (PDF)
  • Guidance and Resources for Long Term Care Facilities: Using the Minimum Data Set to Facilitate Opportunities to Live in the Most Integrated Setting (U.S. Department of Health and Human Services, Office for Civil Rights, May 20, 2016)
  • National MFP Website success stories and videos