The elderly Asian man who walked into the Delonis Center homeless shelter in the spring of 2011 had no identification, but spoke English well. He gave his name as Yashukiko Shiji. At his intake interview, he said that he had a business in Japan that would provide income, but would need a private place at night to make long-distance calls. Staff found one for him, but soon began to doubt the existence of the business: he had no income and didn’t appear to be using the phone.

Looking for a job and housing are prerequisites for the shelter’s residential program. But with no driver’s license or passport, Shiji was ineligible for Section 8 housing, food stamps, or Social Security that might have paid for his housing and food. Shelter staff were able to arrange health care coverage, through the Washtenaw Health Plan and a Medicaid program that covers emergency services.

Operations specialists Erin Stanley and Rebecca Elias met the man they call “Mr. Shiji” soon after he arrived. They would see him staring at a wall or ceiling for hours. Attempts to interact with him triggered fits of escalating anger. He responded to questions, in English or Japanese, with silence, single words, or short clipped phrases.

He wasn’t able to handle being near other people, wore gloves all the time, and was obsessive about what he would touch. “Doing a load of laundry was a fiasco,” Elias recalls. “If one sock fell on the floor, he wanted to rewash everything.” Despite his painstaking efforts to avoid contamination, he had poor personal hygiene. He refused to use the shelter’s public restrooms and demanded new underwear each time he was incontinent.

It was clear that Shiji had severe mental illness, but he refused medical or psychiatric evaluations, so shelter staff couldn’t get an accurate assessment or arrange treatment. It would eventually take four years, and the coordinated efforts of multiple social service agencies, health care providers, and two governments to get him back to his hometown in Japan.

Details about Shiji’s past are sparse, but the best guess at the shelter was that he had come to U-M in the 1970s to attend graduate school. As his mental illness worsened one of his professors took him in, and he lived there for over forty years. When the professor died, his widow could no longer care for Shiji and delivered him to the shelter.

By the following spring, it was clear that Shiji couldn’t meet the requirements of the residential program. Shelter staff contacted a Wayne State University immigration clinic to see if they could help; they couldn’t. They contacted U.S. Immigration and Customs Enforcement (ICE), only to be told the agency’s current focus was on high-profile cases; since Shiji wasn’t committing any crimes, they wouldn’t act.

Leaving the residential program meant Shiji would no longer have a cot and a locker at the shelter. But he remained eligible for meals, case management, services at the health clinic, and the warming and cooling centers. Stanley suspects that in good weather he sometimes slept on a nearby front porch.

In December 2012, Stanley left the shelter to work for the U-M Complex Care Management program, which coordinates care for patients with the highest level of need, including physical and mental illness, homelessness, and lack of health insurance. It streamlines services by working with patients’ medical and home caregivers, community providers, and support agencies. Stanley became Shiji’s case manager there.

That winter, Shiji spent a lot of time outdoors. He had no boots, and in the spring of 2013, warming center residents began complaining about a horrible stench that filled the room when he took off his shoes. Shiji was hospitalized with trench foot and ulcers on his legs, probably caused by continually wearing the same wet socks, long johns, and clothes.

Stanley saw the one-week hospital stay as an opportune time to seek mental health care. Shiji was diagnosed with obsessive-compulsive disorder and psychosis, but he fought his transfer to the U-M psychiatric unit. Stanley and the UMHS treatment team petitioned the probate court to admit him involuntarily and approve an alternative treatment order (ATO) requiring him to continue treatment after discharge. The court granted it, subject to review in ninety days.

Stanley found funding for Shiji’s medications through MSupport, the hospital’s charity program, and a U-M psychiatrist to work with him and administer his injections. He respected the judge’s authority and generally complied. The shelter agreed that after his treatment was done, he could again be a full-time resident. Stanley says Ellen Schulmeister, the shelter’s executive director, “was horrified at what he had been through and basically said, ‘We have to do this.’ “

Though he no longer had to seek employment or housing, Shiji was required to shower each Friday. He insisted on a private bathroom, with clean towels to cover the floor and a new bar of soap each time he showered. He stockpiled towels so compulsively that eventually staff had to lock the cabinet. And he again became uncooperative during medical appointments.

When the court order expired that summer, Shiji objected to continuing treatment. Stanley and the U-M psychiatrist went back to court. “We saw this as vital to him staying at the shelter,” she recalls. “Without his medication it was too difficult for staff to work with him.” But Shiji no longer seemed an immediate risk to himself or others, so the judge didn’t renew the order.

Once he stopped taking his medication, Shiji began struggling and making vague suicide threats. He was taken back to the psych unit, then discharged to the shelter. Finally, through the efforts of the shelter and the U-M, the court approved a yearlong ATO.

Then, in January 2014, Shiji fell and broke his collarbone. He was hospitalized, and a U-M geriatric neurologist later confirmed that Parkinson’s disease, in combination with his OCD-related inability to use his hands to steady himself, were behind his frequent falls. He returned to the shelter, but continued to have frequent falls and trips to the hospital.

Elias, meanwhile, had started working at the federally funded Frequent Users System Engagement (FUSE) program, intended to help “communities identify and engage high utilizers of public systems and place them into supportive housing to break the cycle of repeated use of costly crisis services and involvement in shelters and the criminal justice system.”

Stanley applied to FUSE for housing funding for Shiji. It was approved in June, and Elias became his FUSE case manager. When they told him he’d soon have housing, Elias and Stanley saw him smile for the first time.

“Everyone was very excited at this point, especially at the shelter, where they were able to get this basically unhouseable man into housing,” Stanley says. “The fact that the shelter kept him long enough until he was able to get into FUSE, and that FUSE was willing and able to work with him, was a huge success.”

But before they could find him housing, Shiji fell again and went back to the hospital. Now his care team agreed he couldn’t live independently–he needed home care. He returned to the shelter temporarily while his team looked for an apartment and funding for care–but then another fall sent him back to the hospital.

This time shelter management told the U-M he couldn’t come back, because he needed more care than they could provide. He was transferred to a hospital observation unit until Stanley persuaded Michigan Visiting Nurses to arrange support for him as a charity case.

Once care was lined up, Avalon Housing found Shiji an apartment. Stanley arranged his medical and home care schedules and helped Elias find clothing, furniture, food, and housewares. Once he moved in, they took him to medical appointments and coached his caregivers.

But “much of what we did was basically problem-solve around his behavior,” Stanley recalls. Shiji rarely left his bed and refused to shower or flush the toilet. Caregivers grew so uncomfortable that “they would kind of not want to give him services,” Stanley says. “So, we’re kind of coaching them–‘he still needs this, so what do we do?’ … we were constantly putting out fires; it was just constant crisis and behavioral management.”

Why did Elias and Stanley persist? “Everybody says that they meet people where they’re at,” Elias says, “but the challenge is to stay there with them, not needing them to have certain behaviors to get their needs met, not reaching out your hand and dragging them into your vision for them. We never expected him to be different to get his needs met.

“It’s easy to criticize. But when you have a helpless human being in front of you, helping them is the right thing to do.”

Now help came from Shiji’s home country. Elias emailed the Japanese consulate in Detroit, and staffers Kenji Hashimoto and James Figurski came out to meet Shiji in his apartment.

To the astonishment of Elias and Stanley, when they arrived Shiji shook hands with Hashimoto–something they’d never seen their germophobic client do–and immediately engaged him in animated conversation. “We had no idea what they were talking about since they were speaking in Japanese, but we were just were smiling,” Stanley recalls. “We’d never heard him have a real conversation with anyone.”

Hashimoto and Figurski began to visit Shiji, and Hashimoto told him how important it was for him to respect his caregivers. “It didn’t always work perfectly, but it would change Shiji’s behavior for a short while,” says Elias.

Hashimoto’s research in Japan revealed that Shiji was seventy-two and a native of Osaka. The consulate took steps to get him a passport, and Shiji’s support team began to discuss returning him to Japan.

Shiji was again refusing his medications. He was having difficulty swallowing, which, combined with poor diet and depression, caused his weight to plunge. The judge approved his ATO for another year. With his weight down to 101, a visiting psychiatric nurse told Stanley that he would likely need to be hospitalized soon.

In January 2015, Hashimoto delivered Shiji’s passport. He later emailed Stanley to say that Osaka was willing to consider finding a place for him. Shiji, who had previously resisted the idea, began to come around. With arrangements in place for long-term health care and housing, he finally gave his consent, saying, “I agree. It’s time for me to go home.”

Elias and Stanley were stunned to learn that this would not be Shiji’s first deportation: ICE had even put him on a plane in 2008. Shiji denied this, but when Hashimoto showed him the official paperwork, admitted that he had felt sick and was allowed to leave the plane.

Given that history and his deteriorating mental and physical condition, it was agreed that Stanley and Elias would accompany him all the way to Osaka. The Detroit consulate requested his deportation so that ICE could make travel arrangements and pay for his flight. U-M and a private donor contributed $7,000 for the care managers’ travel expenses.

Hashimoto drew up a contract for his return. Elias says that getting his signature in the past had been “like pulling teeth. He’d snort at the paper and ignore it, taking hours to give a signature. But when Mr. Hashimoto asked, he picked up the paper and signed it.”

In May, Shiji fell again. This time, he was diagnosed with a minor heart attack and weakened muscles. His speech became garbled, but he was more amenable to the occupational and physical therapy that would give him strength for his trip. Elias and Stanley visited him daily, encouraging him to participate in his therapy and coordinating his care. Because the hospital in Japan didn’t have wheelchair access, they helped him practice walking and climbing stairs.

When Shiji was released from the hospital in June, Elias and Stanley picked him up and took him directly to Detroit Metro airport. Joined by Hashimoto and Figurski, they met officer Joseph Salvatera of U.S. Citizenship and Immigration Services. Salvatera helped them through security, stayed with them until boarding, and briefed the flight crew, who in turn arranged an escort to help Shiji and his caregivers off the plane and through customs in Japan.

The half-day flight and four-hour train ride to Osaka went as planned. But despite the meticulous arrangements, Stanley says, “We were turned away from multiple hospitals before finding one to accept him, and made multiple trips to [a district] office where we had to sit for hours, struggling to communicate and feeling powerless.”

Once again, the Detroit consulate came through. “While we were working with social services, Mr. Hashimoto was available by phone to translate and help explain the situation, even though it was the middle of the night in Detroit,” Stanley says. “To say that we would not have been able to do this without Mr. Hashimoto’s compassion and dedication is an enormous understatement.” With his help, Shiji was eventually admitted to an Osaka hospital.

“Mr. S. started to slowly open up towards the end of the trip,” Stanley recalls. “Even though he expressed fear that we were leaving him, he also started to translate for us and engage in conversation more with the social services and hospital staff than we were used to seeing him do with his providers in America.”

Goodbyes were difficult and emotional. Shiji imperiously asked Stanley and Elias to tuck him in bed as they were preparing to leave. As they did, he softly said thank you to them for the first time.

Hashimoto has since returned to Japan. He let Elias and Stanley know that Shiji improved enough in the hospital to transfer to a nursing home and then to an assisted living facility.