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An address from an old driver’s license, a name, and a computer. That’s all Michelle Romano Shami, LCSW, assistant director of care management and social work at �ٺ���Ƶ Orthopedic Hospital, had at her disposal when she set out to locate the family of a newly admitted patient with a chronic memory disorder.

The patient, a 53-year-old man who was experiencing chest pain, was taken to Tisch Hospital on First Avenue in Manhattan. Staff there determined there were no active medical issues to resolve, so they transferred him to the new Medicine Care Transitions Unit at �ٺ���Ƶ Orthopedic Hospital because his memory impairment raised questions about his ability to care for himself. The patient had been staying in a men’s shelter in the Bronx since he arrived in New York months earlier and was unable to remember anything except that he was originally from Ohio and had been living in Germany for the past few years.

“Patients with memory issues aren’t that uncommon in our emergency departments,” Shami says. “But we rarely see them on the Medicine Care Transitions Unit. I just had this feeling there was a story here. He had nice, clean clothes, nice luggage, and he just didn’t seem to fit the position he was in.”

“I Think I’ve Found His Family”

Shami’s extensive Google and Facebook searches resulted in a list of potential relatives. She started calling them one by one.

“My goal was to find our patient’s mother. Considering his age, she could be alive, and I thought, there’s no way a mother wouldn’t want to know where her son is,” Shami says. “Unfortunately, I didn’t find his mother, but I was able to find his ex-wife, who put me in contact with his daughter and three siblings: two sisters and a brother, who’d been so worried about him.”

The patient’s situation had become a source of discussion during interdisciplinary care conferences—daily meetings during which a patient’s care team discusses their care plan and treatment. So when the message, “More to follow but I think I’ve found his family,” ticked into everyone’s inboxes late on a Friday evening, there was considerable excitement.

“Our patients are usually here for a while, so we get to know them and get quite invested. Everyone was eager to get him home,” says Marisa DeFilippis, RN, nurse manager on the unit.

“By Monday morning we were full steam ahead, figuring out how to act on the information Michelle had found. It almost felt too good to be true, so we had to find a way to verify that these people were in fact our patient’s family,” DeFilippis says.

A Missed Flight and a Relieved Family

When the patient was returning from Germany, his family had arranged for a connecting flight to Ohio. Unfortunately, he never made the flight, and his siblings had spent months unable to locate him despite multiple efforts. They were ecstatic to learn that he was safe and receiving care at �ٺ���Ƶ, and told Shami they would come to New York to pick him up immediately.

“The first words out of the patient’s mouth when he saw his siblings were ‘Hey sis,’” says DeFilippis. “Then they all embraced. It made me tear up to the point that I had to step away. We were all so excited to see this special moment happen.”

Finally Home

In the following days staff from the care management and social work and nursing teams identified local resources in Ohio that could continue the medical treatment the patient needs. A week later the family reached out to let everyone know they’d made it home safely and to express their gratitude.

“This extraordinary outcome exemplifies how the Medicine Care Transitions Unit elevates patient care in Manhattan. I’m so proud to be part of a team that is passionate and creative enough to solve these seemingly insurmountable issues for our patients.”—Samuel Levine, vice president, �ٺ���Ƶ Orthopedic Hospital

“I’m so happy we didn’t just accept that this man had no one in his life,” Shami says. “And I’m grateful that everyone was all in on making this happen. I never could have imagined that it would work out this well. It makes me proud.”

DeFilippis adds, “If he had gone back into the shelter system that could easily have been the end of it. But that wasn’t good enough. I’m so grateful to have played even a small part in this outcome. This couldn’t have happened without the strong partnership and collaboration across disciplines that we’ve managed to build here.”