Opening Doors to Independence: Helping People Transition Home

 In this episode of the podcast, CEO Bruce Drake sits down with Education and Outreach Specialist Carrie Ann Davis to discuss the Open Doors Program and the life changing impact it has across Central New York. Carrie Ann shares how the program helps individuals transition from nursing homes and rehabilitation facilities back into community living with the supports they need to thrive. From housing barriers and peer support to civil rights and independence, this conversation highlights the power of choice, advocacy, and connection. Plus, hear the inspiring success story behind 86 individuals transitioning back into their communities in 2025. 

Transcript

Welcome And Guest Introduction

SPEAKER_00 0:08

This is the Arise Exceptional Family Resources Podcast with your host, CEO Bruce Drake.

SPEAKER_02 0:14

Hi everyone, I'm Bruce Drake, the CEO at Arise and Exceptional Family Resources, and I'm your host for today's exceptional talk on disabilities. Today we have with us our education and outreach specialist, Carrie Ann Davis, who is here to discuss our open doors program. Welcome, Carrie Ann.

SPEAKER_01 0:30

Hi, Bruce. Thank you. Thanks for having me.

SPEAKER_02 0:32

Oh,

Carrie Ann’s Path Into Disability Work

SPEAKER_02 0:33

our pleasure. So, Carrie Ann, before we tell everyone about the open doors program, why don't we tell everyone about why don't you tell everyone a little bit about yourself?

SPEAKER_01 0:41

Sure. Um, absolutely. I'm originally from the area. I was born in Syracuse. I grew up south of the city a bit. Um ended up staying in state for school. And where'd you go to school? I went to Plattsburgh State.

SPEAKER_02 0:53

Oh, how was that?

SPEAKER_01 0:54

Yep. Fantastic.

SPEAKER_02 0:55

There's not a lot up there in Plattsburgh.

SPEAKER_01 0:57

Not a lot up there, but I'm a mountain girl, so it was perfect for me.

SPEAKER_02 1:00

And what'd you go to school for?

SPEAKER_01 1:01

I went to school for communication disorders and sciences. Okay. Speech language pathology. Yeah. And from there I got into early education, uh, worked with children with special needs, and worked in developmental services in Vermont. So after I graduated from Plattsburgh I moved to Vermont and worked in developmental services there for their OPWDD program.

SPEAKER_02 1:20

Okay. Do you have a personal connection to people with disabilities, or it's just something that always kind of interests you?

SPEAKER_01 1:26

Something that always interested me, but I absolutely made a connection with a specific family when I was teaching early childhood who brought me into their world of developmental services. They had children on the autism spectrum, and I absolutely fell in love with that line of work and went into some training in applied behavior analysis, did some graduate work there, and moved on to service coordination, like I said, with developmental services.

SPEAKER_02 2:00

And actually my daughter is named after her now just because of the connection that we had. And I I think for people who who've never worked in our field or do what we do, I I don't think they realize what a big an impact that the people have on the staff and not just the staff have on the people that we support.

SPEAKER_01 2:17

Oh, absolutely. It was so my Emily was Martha. Okay. And it was not only her, but her family and the advocacy that her mom specifically and her family provided. It really struck me at the time.

SPEAKER_02 2:30

All

What Open Doors Actually Is

SPEAKER_02 2:31

right. So we know a little bit about you, so why don't you tell us a little bit about what the open doors program is?

SPEAKER_01 2:39

Sure. I do want to go back just a little bit, though, and talk about after service coordination with with developmental services. I also did provide service coordination for the traumatic brain injury program and nursing home transition and diversion Medicaid waiver in the Albany region. So that's how I got more into the long-term care programs.

SPEAKER_02 2:58

Okay. Oh, so that makes sense. Okay.

SPEAKER_01 3:00

Yeah. So then and then I taught for a little bit and got into um I did service coordination for the kinship caregiver program here in New York. I was out of state for a while, came back.

SPEAKER_02 3:09

Okay.

SPEAKER_01 3:10

And now doing the education outreach piece and also transition specialist work for open doors.

SPEAKER_02 3:17

Yeah, so what's your full title? Let's let's let's do that. Because you had you had a complicated title.

SPEAKER_01 3:21

Well, it is education outreach specialist.

SPEAKER_02 3:24

Okay.

SPEAKER_01 3:25

More recently, though, uh starting in January, I've taken on some of the transition specialist work. So now I'm really seeing what the work looks like and the folks that we have going into the nursing homes and uh making these transitions happen. Um it's been really great to see.

SPEAKER_02 3:41

Okay.

SPEAKER_01 3:41

Yeah.

SPEAKER_02 3:42

All right. So now let's tell people all about the open doors program.

SPEAKER_01 3:46

Sure. So open doors is the New York State money follows the person program. So Money Follows the Person is a federal initiative to rebalance Medicaid long-term care away from institutional care into home and community-based services.

SPEAKER_02 4:02

So what what for for people who don't know, because I think sometimes they hear the word institution and they have a picture of a big old brick building up on a hill somewhere behind gate gates. What what's the name of the other thing? Not at all necessarily.

SPEAKER_01 4:15

Sometimes they're very supportive, amazing nursing homes. So nursing homes, guild nursing facilities, rehab facilities, those are the sites that we're looking at, identifying folks that want to move into the community.

SPEAKER_02 4:27

Great. Okay.

SPEAKER_01 4:29

So the mission of open doors, like I said, is to transition people to the community and to really support access to community support, to community providers, and resolve any barriers in between.

SPEAKER_02 4:45

So what we're saying is there's somebody who's living in a skilled nursing facility, a nursing home. Right. And they don't want to be there. They'd rather be out in the community. Are those the people that we're

Eligibility And How Referrals Work

SPEAKER_02 4:57

talking about?

SPEAKER_01 4:57

Yes, absolutely. And that kind of gets to eligibility, and the only eligibility requirements are that the person wants to return to the community. Okay. They're 18 years or older, and that they give consent for this to happen, that they desire for it to happen.

SPEAKER_02 5:12

So there there is no I I'm living in a nursing home and I decide, you know what, this isn't for me. I want to move back to the community, so I have to get the nursing home's approval, or I have to get a doctor to approve. It's it's really to be over the age of 18 and have a desire to live in the community.

SPEAKER_01 5:30

That's right. And then the referral is made to open doors. We get a lot of our referrals from social workers. Okay. But anyone can refer to open doors. It can be themselves. It can be a family member, doctor.

SPEAKER_02 5:39

Aaron Ross Powell Would it be the social worker who lives at who works at the nursing home? Yes. Okay.

SPEAKER_01 5:44

Mm-hmm.

SPEAKER_02 5:46

So then what happens? So somebody you get a referral that says, hey, I'm working with Jane Doe or John Smith in this nursing home, and they've expressed a desire to leave. What happens then?

SPEAKER_01 5:58

Aaron Ross Powell Well, one of the main questions we get first is Medicaid required at the time of referral, which it's not. Okay. That's something that a transition specialist w will help with, that Medicaid eligibility, and then making referrals to Medicaid programs.

SPEAKER_02 6:12

Okay.

SPEAKER_01 6:13

From there, one of our open doors transition specialists will go out and do an intake, meet the resident, and eligibility is determined from there. Okay. I do want to go back and talk about who oversees

Assessments Safety And Civil Rights

SPEAKER_01 6:25

open doors. Sure. So the Department of Health contracts with a New York Association on Independent Living.

SPEAKER_02 6:31

Okay.

SPEAKER_01 6:32

Nile oversees our independent living center statewide, including Arise EFR, right? Um so that oversight is there to make sure that these transitions are safe and accessible for folks.

SPEAKER_02 6:44

Just uh to back up for people, so Nile is a New York association of independent living centers. Every county has an independent living center. There's 41 of us across New York State. Uh we are a peer-driven organization that uh does everything it can to help people with a variety of uh disabilities to live independently in their communities. And so Nile is the statewide association that oversees all of that. And it sounds like they have a grant for this and that we report to Nile.

SPEAKER_01 7:15

That's right.

SPEAKER_02 7:16

Okay.

SPEAKER_01 7:16

That's right. And this upholds um the Money Files the Person program upholds the Olmsted decision, which uh said that the unjustified segregation of people with disabilities is law unlawful under the ADA.

SPEAKER_02 7:29

And people need to live in the least restrictive least restrictive environment possible. Trevor Burrus, Jr. Exactly. Yes.

SPEAKER_01 7:35

So that's been a neat part of my role as an education and outreach person. Soon after I started, I realized, oh, I'm actually going out and letting people know what their civil rights are. This is pretty powerful stuff.

SPEAKER_02 7:46

Aaron Powell That is very pro not something I would have thought of, but it it is a very powerful message.

SPEAKER_01 7:52

Yeah.

SPEAKER_02 7:52

So you get the referral and somebody goes out to meet the person, and what are those conversations like?

SPEAKER_01 7:59

Aaron Powell Yeah, well, I also want to go back and talk about um what our team at Arise looks like.

Supports Housing Barriers And Volunteering

SPEAKER_01 8:05

Okay. And and who would go out. So lots of times um it is Holly Aldridge, who's our tran our regional transition manager. Sometimes it is a TS who's under her as well. Um so our transition specialists are Tanisha Wiggins and Peyton Reeves.

SPEAKER_02 8:19

Okay.

SPEAKER_01 8:20

Very skilled people who go out and do amazing work. Um and I've been fortunate to be trained by those ladies to do this as well. It's been really eye-opening, like I said. So they go out and meet the residents and we do our intake paperwork, get their story, get an understanding of what their goals are, um, where they want to live, what kind of supports they might have in the community. And then it's looking at, okay, these are the referrals that um we're looking at making. These are the most appropriate ways to go. We refer to the traumatic brain injury waiver, the NHTD or nursing home transition and diversion medicade waiver. We refer to OPWDD, mental health services. Sometimes it's a housing issue, lots of times it's a housing issue. So we'll refer to housing programs and work closely with them.

SPEAKER_02 9:08

So when you say it's a a housing issue, the issue is that the person might have the ability to live on their own, they just don't have the place to live on their own? Aaron Ross Powell, Jr.

SPEAKER_01 9:15

Exactly. Exactly. So then we'll make a referral to OHS, our homestead housing subsidy, or you know, Section A other programs and see what can be done there in order for accessibility to happen for them.

SPEAKER_02 9:28

And it's it is or isn't your role or the team's role or the social worker's role to make a determination as to whether or not the person can successfully live on their own?

SPEAKER_01 9:40

Aaron Powell No, it's not it's not the determination of open doors necessarily. Like I said, it's it's overseen by the Department of Health and Nile. Yeah. Um but assessments are made, um, you know, nursing assessments are made to make sure that it would be a safe transition for a person. Um and sometimes it's not a safe transition. Sometimes there is a lack of informal supports in the community and it doesn't make sense for that person, unfortunately.

SPEAKER_02 10:04

So you talking informal supports, you're talking about maybe friends or family.

SPEAKER_01 10:07

Friends and family, exactly.

SPEAKER_02 10:08

Sure.

SPEAKER_01 10:09

Along with that, Bruce, you were ta along with the friends and family being available. I wanted to just mention a volunteer opportunity that we have. Um, part of our program is called the Good Neighbor Program. Okay. And so that involves folks in the community who volunteer to be a support for someone who doesn't have friends and family who has transitioned into the community. Okay. Um we also have the peer support program, so that links up someone who has already transitioned out of a nursing home into the community, and we pair them up with one of our participants who is transitioning as well.

SPEAKER_02 10:42

Aaron Powell Do we have a lot of people who volunteer in the program?

SPEAKER_01 10:45

We have a peer support person right now. I'm not sure if we have any good neighbor volunteers at the moment.

SPEAKER_02 10:51

If a listener was interested in in participating in the program, do you know are there any prerequisites the potential volunteer needs or how the best way to get more information about it?

SPEAKER_01 11:02

I do have a contact phone number for good neighbor, which I can share here and maybe we can so that number for good neighbor is 518-465-4650.

SPEAKER_02 11:13

Why don't you say it again?

SPEAKER_01 11:15

518-465-4650. Okay. Perfect. And that is 844-545-7108.

SPEAKER_02 11:30

For the for the people who are looking for your assistance, is there a cost to them?

SPEAKER_01 11:35

There's no cost for the open doors program.

SPEAKER_02 11:38

So this is all covered by the Nile grant? It is. From State and Federal Funds.

Success Numbers Common Challenges And Wrap Up

SPEAKER_02 11:44

Okay. So are there any success stories that you might be able to share without giving out any confidential information, obviously. But maybe somebody who's gone through the program and how their life has changed?

SPEAKER_01 11:56

There are success stories, definitely. I would like to share a success number.

SPEAKER_02 12:01

Okay.

SPEAKER_01 12:02

And um so Bruce, at our monthly staff meetings, you start off with a question. Uh-huh. So I have a trivia question for you. Uh oh. But you can't guess too high. All right. So the So the question is how many people transitioned out of nursing homes in the Syracuse region in 2025? So keeping in mind that the Syracuse region is a is it seven or eight counties? Okay. Don't go too high because you don't have to be able to do that.

SPEAKER_02 12:32

I'm not going to go too high because I'm I'm not optimistic about this. I know we have fantastic staff. Trevor Burrus, Jr.

SPEAKER_01 12:36

But in really considering those people now living in their homes in the community.

SPEAKER_02 12:41

So I uh the the number that pops into my head is somewhere around 10 to 15.

SPEAKER_01 12:47

We had 86 people transition in 2025.

SPEAKER_02 12:51

Well, that is a success number. I would agree with you completely. So 86 people who were living in an institution who did not want to be there are now living more independently in in their communities. Yes. That's a great that's a great success number. It is. Wow. Well done. Well done to you and all of your staff. So thank you very much. Is there a particular struggle that you see that people might face when they're they're looking to transition?

SPEAKER_01 13:17

As I mentioned, the um difficulties with the accessibility of housing is a struggle, and the lack of informal supports can be a struggle. Folks that don't have friends and family to help support them. Okay. Eligibility for other programs like TBI and NHTD, there can be holdups there. A transition can be a long process to make sure that it's safe. It really depends on the case.

SPEAKER_02 13:44

So it could be six months, it could be two years?

SPEAKER_01 13:48

I would say so.

SPEAKER_02 13:49

Okay. So it really depends on the individual's needs and their personal circumstances, where they want to go, the supports that they have to get there.

SPEAKER_01 13:56

That's right.

SPEAKER_02 13:57

I I love hearing about this program. And what was the number again? 86?

SPEAKER_01 14:02

Oh, 86 people transit.

SPEAKER_02 14:04

86 people who trans. That's a success story. Uh as we talk about as an organization about our achievements each year, that's that's a number that we should certainly be talking about. Uh Carrie Ann, thank you so much for finding the time to talk with us today. Ladies and gentlemen, that was Arise Exceptional Family Resources Education and Outreach specialist Carrie Ann Davis, talking about the wonderful open doors program and the wonderful work that they do. Uh, thank you all for listening, and we hope you join us next time as well.

SPEAKER_00 14:33

This has been the Arise Exceptional Family Resources Podcast with CEO Bruce Drake, recorded and produced at the WCNY public broadcasting studios. For more information, visit our website at contactefr.org. You can also follow us on Facebook. Thank you for listening.