Case Manager Insights

Helping “Jerry” Return Home

Cassandra Wadlington, MSM, MSN, BSN, RN, ACNE, CEN, TNS

In my job at a major acute care hospital, I learned of a developmentally delayed patient with minor physical disabilities who had been abandoned by his family. He had been hospitalized for many months. Jerry was initially admitted for “seizures” in early February 2020. I realized I needed to investigate and uncover the back story.

Upon speaking to the emergency contact/next of kin, a sister, I discovered that in fact Jerry wasn’t abandoned. However, due to the sister not being a United States Citizen and her living situation with friends, she could not assume responsibility for her brother. She also informed me that Jerry was not a US Citizen; he was from a Caribbean Island where he still had family. The sister relayed that Jerry, her half-brother, was brought to the United States by their father. She happened to meet Jerry when visiting her father one day. Jerry had been living with their father and Jerry’s step-mother until both parents passed away. Then Jerry was cared for by other family members until they too passed away.

I reviewed the chart and learned that Jerry was alert and oriented, and able to answer questions appropriately. I went to visit him and had a conversation, which showed me he had some developmental delay, but was appropriate and answered all of my questions fully. He was able to provide the name of his mother, father, and sisters, and said that he wanted to return to his island home and “all the good food.” I contacted his sister to see if she would be returning soon and suggested that we might help make arrangements for him to return with her. She was hesitant, and then refused, saying she

would be returning, but not soon.

Because there was no medical reason for his continued hospitalization, I contacted the island nation’s consulate in the US for assistance. I was referred to the Consul General at the Embassy in Washington DC. The Consul took the call and confirmed Jerry’s citizenship and agreed to assist with locating family on the island to accept and support him upon his repatriation.

After locating an elderly cousin who still lived there, we learned that Jerry’s mother had also passed away and no other siblings could be located. The cousin was unable to care for him due to her age, physical disability and financial constraints. With this information, I understood that I needed to learn if there were any facilities that could care for Jerry on the island.

The only assisted living facilities there are for the elderly. There is nothing for the developmentally delayed. It was now September, Jerry was stable, ready for discharge, and asking to go back home because he liked it there. I continued working with the embassy as well as with his sister.

Then one day, I was informed by the embassy that there was a retired medical worker willing to care for Jerry on the island, and that the embassy was making arrangements for Jerry to go home. The only thing stalling his trip home was the COVID-19 pandemic, which had stopped all flights between the island and the US until October 1, 2020.

Due to his disability the decision was made that someone would have to accompany Jerry on the trip home. I was chosen for the task. While waiting for the day of departure, I had multiple visits with Jerry to keep him informed of what was happening and to ensure his comfort level with the discharge plan and with me as a traveling companion. We also kept his sister informed of Jerry’s status and discharge plan.

Working with the embassy and the Minister of Health on the island, we coordinated Jerry’s new residence and finalized the plans for who would provide care once he was repatriated. Jerry was provided with a donated ticket, clothing (purchased and donated by the staff at the hospital), a 6-month supply of medication, a wheelchair, and personal protective equipment.

On October 3, 2020 Jerry was discharged and I traveled with him. Upon continues on page 35

Cassandra Wadlington, RN, MSM, MSN, BSN,

ACNE, CEN, TNS, is the Manager Transition of Care, IP Social Workers, Transfer Service, Cook County Health, Chicago, Illinois.

In my job at a major acute care hospital, I learned of a developmentally delayed patient with minor physical disabilities who had been abandoned by his family. He had been hospitalized for many months. Jerry was initially admitted for “seizures” in early February 2020. I realized I needed to investigate and uncover the back story.