Ebony James

Background

About Ebony James

Coordinate care for chronically ill clients identified from NYS Department of Health -Collaborate with support team consisting of PCP’s, Mental Health Providers, Substance Use Clinicians, and Specialists, in order to prevent ER admissions and hospitalizations -Maintain caseload consisting of 40 members; conducting monthly visits to ensure well being -Complete housing applications (HRA2010E, NYC Connect, NYCHA) for members in need of secure and stable placement and / or assist with connecting to NYC brokers for City Feps Vouchers -Connect members with referrals for medical, mental health, substance use services, communi- ty support programs, home attendant services, DD, and transportation services -Generate patient centered care plans geared to assist clients with achieving their individualized goals -Care Coordinator for the Adult Home Initiative: weekly case conference with DOH & OMH providing updates regarding client/ housing status, collaborated with various housing contractors to aid in assistance with transitioning adult home clients back into the community based on their level of approved housing, weekly case conferences with social workers, ensure clients are connected to all entitlements/ have all identifiable identification prior to transition