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WELCOME TO BAYHEALTH MEDICAL CENTER!We are here to serve your needs and provide you with the highest quality of service and care.

To help us serve you better, we ask for your feedback. If you have any concerns or questions, please feel free to speak with your nurse, physician or Patient Advocate.

As we continue our “Service Excellence” commitment to caring for our patients, we have become a “Planetree” affiliate. This means we are committed to serving you in a patient-centered environment that focuses on your physical, mental, emotional and spiritual healing.

Bayhealth Medical Center stands ready to fulfill our mission “to improve the health status of all members of the community.” We know you will see and feel our commitment to quality, care and service throughout your stay.

Terry M. Murphy, FACHE

President and Chief Executive Officer

Bayhealth Medical Center

Our Mission: To improve the health status of all members of the Bayhealth Community.

Our Vision: To distinguish ourselves as a regional health system that consistently delivers an exceptional patient experience by providing care that exceeds nationally recognized standards in a safe, patient-centered environment.

Our Values: Compassion. We are kind and caring to our patients, families and each other.Integrity. We do the right thing. We strive to build trust and are dedicated to

ethical and responsible behavior.Teamwork. We value collaboration and cooperation with patients and members

of the Bayhealth team.Accountability. We treat everyone we encounter with kindness, dignity and

professionalism. Respect. We treat everyone we encounter with kindness, dignity and

professionalism.

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WHAT IS BAYHEALTH MEDICAL CENTER?Bayhealth Medical Center includes Kent General Hospital (KGH), Milford Memorial Hospital (MMH) and multiple locations throughout central and southern Delaware including laboratory, diagnostic imaging and employed physician offices. We believe in maintaining the access and personal care that is so vital to the spirit of a community hospital while also providing the most advanced medical care and technology available.

Bayhealth is one of 500 hospitals and medical centers around the world to affiliate with Planetree. Planetree is a non-profit organization that helps patients, families and staff members deliver care from the patient’s perspective. Since 2005, Bayhealth has been incorporating Planetree’s patient-focused model of care, centered around a holistic approach to healing in all dimensions – “the mind, body and spirit.” Some Planetree components Bayhealth has introduced that are conducive to healing include 24-hour patient directed visitation, pet assisted visitation and aromatherapy.

We are committed to providing the utmost in service and care to you and your family. Friends and family outside the local Dover/Milford calling area who wish to speak with you during your hospitalization can call our incoming toll-free number, 1-888-761-8300. The caller will need to give our operator your name and whether you are hospitalized at Kent General or Milford Memorial.

NOTE: If you have “opted-out” for privacy reasons, the operator will only be able to tell your callers there is no one admitted at the hospital by that name.

This booklet is designed to provide you with information to assist you in being actively involved in making decisions about what happens to you.

We hope you will take the time to review this booklet and if you have any questions about the information provided in this handbook, please contact the Patient Advocate Department:

Kent General Hospital (302) 744-7085

Milford Memorial Hospital (302) 430-5126

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CONTENTSYour Care Team in the Hospital .......................................................................................4

Physicians ~ Nursing Staff ~ Chaplaincy ~Care Management

Patient Advocacy Department .........................................................................................5

When You Are A Patient ....................................................................................................6Opt-Out ~ Language Interpreters ~ Telephones ~Use of Home Medications ~ Personal Belongings

Safety and Security............................................................................................................9Wristbands ~ Bed Side Rails ~ Tobacco-FreeEnvironment ~ Infection Prevention ~ MedicalEquipment ~ Secured Entrances

Food Services ................................................................................................................... 10Guest Trays ~ Stork Club ~ Special OccasionMeals ~ Fruit Baskets ~ Cafeteria Hours

Visitation ............................................................................................................................ 11Guidelines ~ Out of Town Visitors ~Valet & Parking ~ Flowers ~ Gift Shops ~ Balloons

Bayhealth Medical Center Pain Mission Statement ................................................... 13

Patient Rights in Pain Management .............................................................................. 13

Patients Responsibilities in Pain Management ............................................................. 14

Bayhealth Pain Assessment Scale .................................................................................. 14

Discharge Information ..................................................................................................... 14Leaving the Hospital ~ KGH Discharge Suite ~Home Health Care

Advance Health Care Directive .................................................................................... 15

Ethics Consultation ............................................................................................................ 18

Organ & Tissue Donation ............................................................................................... 19

Hospital Billing .................................................................................................................. 21

Patient’s Rights .................................................................................................................. 22

Patient’s Responsibilities .................................................................................................. 27

Other Helpful Information .............................................................................................. 29

Frequently Called Numbers ........................................................................................... 31

Nondiscrimination Policy ................................................................................................. 32

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YOUR CARE TEAM IN THE HOSPITALPhysiciansThe physician who admits you to the hospital is the doctor who has primary responsibility for supervising your treatment. This physician will monitor you closely and write orders that determine what medicines, tests, therapies and procedures you receive. He or she will also determine when you are ready to go home. If your primary physician has chosen to focus only on an outpatient practice, you may have a Hospitalist (a physician employed by Bayhealth to streamline admissions and manage your care) assigned to you to coordinate your inpatient care.

Nursing StaffYour nursing care team is multidisciplinary, including professional registered nurses and assistive staff. These dedicated men and women work as a team around the clock to carry out your treatment program. Patient and family education is an integral part of the nursing care provided. Throughout your stay and before you go home, members of the nursing staff will give you important information about your condition and ways to speed your recovery.

Care ManagementCare Managers are assigned to each patient care area. They can help patients and families deal with problems related to illness or hospitalization. Social Service staff members assist with discharge planning, including home health care, rehabilitation services and placement in a short-term skilled nursing facility or nursing home.

Chaplaincy Services/Pastoral CareBayhealth employs a full-time chaplain who manages the Pastoral Care Department, which includes one part-time chaplain, and coordinates the On-Call Chaplain and Pastoral Care Volunteer Programs.

During times of crisis, loss, and grief, visits to patients and family members are available 24 hours a day to provide emotional and spiritual support and comfort. After hours, an On-Call Chaplain can be reached by dialing “0” for the operator.

Assistance with religious rituals such as scripture, prayer and the Sacraments, as well as weekly chapel services, are available at both KGH and MMH.

Many of the local congregations have a volunteer who comes to the hospital on a regular basis to visit those of the same faith. If you would like to a visit, please contact Pastoral Care or the Patient Advocate Department. Your own clergy is welcome to visit you while you are a patient as well.

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The Chapel at each facility is non-denominational and available 24 hours a day for prayer, meditation or special needs. There are supplies of religious literature, scriptural resources, as well as a prayer rug available for use.

The Rest of Your Care TeamDuring your stay you will come in contact with a number of other health care professionals and support personnel. Phlebotomists will draw blood for analysis in our laboratories. Technologists from Diagnostic Imaging, Respiratory Therapy and other departments will perform special procedures ordered by your physician. Registered dietitians will ensure you receive a healthy, well-balanced diet. Environmental Services and Plant Operations workers will keep your room clean, comfortable and in good working order. Behind the scenes there are secretaries, managers, technicians, clerks, administrators and others, all working together to make your stay and care at Bayhealth Medical Center the best it can be.

PATIENT ADVOCATE DEPARTMENTSometimes referred to as Customer Service, Patient Advocate, Guest Relations or the Complaint Department – the Patient Advocate Department is all of that and more!

A variety of programs and services come under the Patient Advocate/Guest Relations umbrella, such as:

• Aromatherapy • Lending Library • Arts & Entertainment Program • Lost & Found • Caring Touch • Notary Services• CaringBridge • Patient Advisory Committee • Clothing Closet • Patient Advocacy• Complaint & Grievance Investigation • Patient Focus Groups • Honors & Service Excellence Recognition • Pet Therapy • Information Desk • Therapeutic Distraction

The Patient Advocate Department can be reached at (302) 744-7085 (KGH) or (302) 430-5126 (MMH). Staff are on site from 7:30 a.m. to 4:00 p.m. Monday – Friday, and there is always someone on call for those occasions that just can’t wait. After hours please contact the house supervisor through the operator by dialing “0.”

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WHEN YOU ARE A PATIENT“Opt-Out” – Are you sure? As a patient, you will be given the option of your name being known or unknown in our system. If you choose to “opt out” of our system, we are not able to give any information about you – including whether or not you are even a patient at Bayhealth. This includes providing any information to your family members, potential visitors or being able to accept floral deliveries for you. This is in compliance with a federal regulation. NOTE: If a patient has opted out, no information can be given to anyone.

Sign Language and Foreign Language InterpretersTo ensure effective communication with patients and their companions who speak a foreign language and/or are deaf or hard of hearing, Bayhealth Medical Center will, to the best of our ability, provide free, understandable information to patients, parents, and/or legal guardians or companions. Sign language and foreign language interpreters are available through Language Line and Deaf Talk, and in-person interpreters are available based on the particular circumstances.

Other types of special needs assistance include:

• Text Telephones (TTYs) available free of charge to people who need them

• Telephones that are hearing aid compatible

• Volume controlled, amplified handsets

• Closed Captioning for television

• Handicapped parking

• Large print patient handbooks

For more information, please contact your nurse or the Patient Advocate Department.

TelephonesUnlimited local calls are available from the bedside phone by dialing 9 and the number.

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Use of Home Medications During Your Hospital StayThe Pharmacy at Bayhealth Medical Center stocks the most commonly prescribed medications. We encourage the use of medications supplied and given by the hospital at all times.

There are times when the medication that you have been taking at home will not be available at the hospital, in which case permission may be given to bring in medication from home.

Under certain conditions, your doctor may let you use your own medications. If there is not a reasonable substitute for your medication, or if you are participating in a research study, your doctor will write an order for you to take your medications from home.

All medications brought to the hospital from home must be in their original container and properly labeled with name, dose, strength, route, and directions for use. These medications are normally kept in the medication cart on the nursing unit where you are admitted. Your nurse will make sure that these medications are given as ordered during your hospital stay.

Some home medications may also be kept at the bedside if ordered by the doctor, such as breathing treatment medications. If this is permitted, your nurse or respiratory therapist will instruct you to use your own medication during your hospital stay. Before taking your medication, you will be asked to use your call bell to let the nurse know that you are taking your medication.

If you use all of your medication while hospitalized and you do not wish to take the empty container home, please give it to your nurse or therapist. Medication containers frequently include patient information that can be used to identify you or your illness. Your nurse or therapist will make sure these items are discarded in a manner to ensure confidentiality.

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Personal BelongingsThe hospital cannot be responsible for items you bring from home and suggests you do not bring unnecessary items. Bayhealth will not reimburse you for lost or stolen property.

• Please send your clothing home with a family member or friend. Bayhealth Medical Center supplies bags for this purpose.

• If you must keep personal belongings, please be sure they are properly labeled with your name.

• Please send home money, credit cards, checkbook, purses, wallets, cell phones, jewelry and any other valuables. If you must have them, please let the nursing staff know so they can be put into the safe. We are unable to accommodate large items.

• Please be careful with your dentures and hearing aids. Do not wrap dentures or hearing aids in tissue or napkins, nor place on food trays, in drinking cups or in bedding. Ask your nurse for a sturdy plastic container if you do not have one. Make sure the container is clearly marked with your name.

• Please label eyeglasses with your name. Use an eyeglass cord or glass case. Do not wrap eyeglasses in tissues or napkins, and do not lay them on food trays or in bedding. Please send contact lenses home if possible. Please use a contact lens case for storage if you must wear contacts.

If you cannot locate a personal belonging, please notify your nurse immediately and we will do our best to help you find it. Unclaimed articles are handled by the Patient Advocate Department. To report a lost item, call our Lost and Found line at (302) 744-6800 or (302) 430-5100 (MMH).

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SAFETY AND SECURITYWristbandsPlease do not remove the identification band that is placed on your wrist. It is for your protection and helps us care for you. Caregivers may check your identification band several times during your stay before doing certain tests and procedures or giving medications. There may be several different bands used during your treatment to identify allergies or other conditions.

Bed Side Rails If the side rails on your bed are in the UP position, it is for your protection. Do not attempt to climb over them. Do not lower them without first consulting your nurse. If you are a risk to fall, you may also have a bed alarm. If you need assistance at any time during your admission, never hesitate to call a nurse.

Tobacco-Free EnvironmentAs of January 1, 2010, Bayhealth became entirely tobacco-free. The use of tobacco products is prohibited in all hospital buildings and on our grounds. Please respect our neighbors by not using tobacco products on their property, and discard used tobacco materials and butts properly.

Infection PreventionHandwashing is the best way to prevent the spread of disease. Additionally, if you are on isolation precautions, please ensure you and your visitors follow the instructions posted at the room.

Medical EquipmentPlease do not try to reset any medical equipment. If there seems to be a problem or the alarm is sounding, please notify your nurse immediately.

Secured Entrances after 8:00 p.m. For the safety of our patients and employees and to provide a secure environment, the hospital may lock the main entrances after 8:00 p.m. ID may be requested in order to provide a secure environment for our patients and staff.

At Kent General Hospital, visitors can access the main lobby through the garage, first floor entrance as that door will remain open 24/7. The Emergency Department entrance will be staffed 24/7 and open to visitors and guests as well.

To gain entrance at Milford Memorial after hours, please have family/visitors come to the Emergency Department.

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FOOD SERVICEKGH: (302) 744-6368 MMH: (302) 430-5606

Wholesome, nourishing and well-balanced meals are an important part of your treatment and recovery. While every effort is made to provide an attractive, appetizing meal, your menu may be limited to certain foods if your physician prescribes a special diet. One of Bayhealth’s registered dietitians or hostesses may work with you on food selections. If you have a special request, please contact your Food Service Hostess or your nurse. You may write special requests directly on your menu and they will be honored if they meet with your dietary guidelines supplied by your physician.

Rooms located on the Women and Children Services units are offered a special Room Service menu between the hours of 7:00 a.m. and 6:00 p.m. Simply place a call to our Food Services offices, place your order and your meal will be delivered within 45 minutes.

Our goal is total patient satisfaction. If at any time during your stay you would like to share your ideas, suggestions or concerns about your meals, please contact our General Manager of Food Services at (302) 744-7154 (KGH) or (302) 430-5607 (MMH).

Guest TraysGuest trays for family members or other visitors are available for a small fee. Please notify us at least three hours before the meal by calling Food Service. Money will be collected when the tray is delivered.

Stork Club or Special Occasion MealsPatients and their families can arrange to celebrate the birth of their child or another special occasion with a special gourmet dinner. Entrees can be selected from a special menu. To get price information please contact Food Services. This meal requires a 12 - 24 hour advance notice.

Fruit Baskets – Standard and GourmetFruit baskets are available in both small and large sizes. These will be available the next day. Gourmet fruit baskets are also available. These baskets include fruit, crackers, cookies and candy. For price information or to order, please call Food Service. These will be available the next day.

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Cafeteria Hours - Kent GeneralLocated in the basement. Take the elevators in the six-story 1986 building. Hot food is not available after hours. 6:30 a.m. – 10:00 a.m. = Breakfast 10:00 a.m. – 11:00 a.m. = Continental Breakfast 11:00 a.m. – 1:30 p.m. = Lunch 1:30 p.m. – 3:45 p.m. = Beverages & Snacks 4:15 p.m. – 6:30 p.m. = Dinner 2:00 a.m. – 3:30 a.m. = Overnight Service

Cafeteria Hours – Milford MemorialLocated on the first floor. Hot food is not available after hours. 6:15 a.m. – 10:00 a.m. = Breakfast 10:00 a.m. – 11:00 a.m. = Continental Breakfast 11:00 a.m. – 1:30 p.m. = Lunch 1:30 p.m. – 4:00 p.m. = Beverage, Deli and Snack Bar 4:00 p.m. – 6:00 p.m. = Dinner 2:00 a.m. – 3:30 a.m. = Overnight Service

Vending Machines/Coin CafeVending machines are available at the Emergency Department entrances at KGH and MMH. Additional machines are located in Hallway #6 at KGH and near the cafeteria at MMH.

VISITATIONVisitors can be good medicine for our patients. While we do permit 24-hour visitation, there is also the understanding that patients in the hospital need their rest. To ensure the proper balance of rest and well-wishers, Bayhealth Medical Center has established specific visiting guidelines for each unit – please check with your nurse.

In order to best meet the patient’s needs and to help the nurses caring for the patient, we ask that the family select one spokesperson who will be able to call the unit at any time for an inquiry and update on the patient. The rest of the family will be expected to contact the spokesperson for timely updates.

We also ask that relatives and friends observe the following guidelines:

• Patients have the right to receive the visitors they designate.

• Visiting is encouraged as long as the patient’s condition and/or physician request allows.

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• Rest and quiet are essential. Keep noise levels low. Please supervise young visitors and children. For the safety of the child, children must be supervised at all times by a responsible adult other than the patient.

• Please wash your hands when entering and leaving the patient’s room.• People with colds, sore throats, or any infectious illness should not visit

patients. Masks and gloves are available at the entrances.• No alcoholic beverages may be brought into the building. • Visitors should not bring food or drink to the patient without first obtaining

permission from a nurse or the attending physician.• Smoking is prohibited in all areas of the hospital.• Visitors may be asked to leave the room during tests, treatments, or under

other circumstances. Please follow the instructions and suggestions of the nursing staff, who will maintain contact with family and return them to the patient’s bedside as soon as possible.

• If you are visiting a patient in an Isolation Room, please see the nursing staff before entering the room.

• In respect for patient privacy and well-being, and as a courtesy, the preferred number of visitors in a semi-private room may need to be limited.

Out-of-Town VisitorsOut-of-town family and friends can receive listings of area hotels and restaurants. For further information, please contact the Information Desk or the Patient Advocate Department.

Valet & ParkingValet Services are provided free of charge. Valets are clearly identified by their shirts and jackets. The hours of operation are:

KGH: 6:00 a.m. – 9:00 p.m.MMH: 6:30 a.m. – 8:30 p.m.

For your convenience, KGH provides a Shuttle Bus from the self-park lot on the north side of the hospital to the Main Entrance from 6:00 a.m. – midnight daily.

Flowers Flowers sent to the hospital through local florists will be delivered promptly to your room. Internet orders are normally delivered to the Warehouse and may be delayed. Occasionally, flowers are delivered to the nursing unit after the patient has been discharged. Every effort will be made to get the arrangement back to the florist for delivery to the patient’s home. Flowers in water can be brought or sent to all patients. However, plants in soil are not allowed in Critical Care, Intensive Care or Cardiac Care Units.

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Gift ShopsAt KGH, the Retail Shops at Bayhealth are located on the first floor and include a Grab & Go area, refrigerated foods section, panini grill, baked goods, milkshakes, flavored coffees and an assortment of gifts, magazines, newspapers, cards and jewelry. The Mother-Baby Shop is across from the Retail Shops.

At MMH, Reflections Gift Shop is located near the main entrance and offers an assortment of unique gift items, snacks, refrigerated beverages, magazines, newspapers, cards and jewelry.

BalloonsTo protect our latex-sensitive patients, Latex Balloons are not permitted in either Kent General Hospital or Milford Memorial Hospital. Mylar balloons are permitted.

BAYHEALTH MEDICAL CENTER PAIN MISSION STATEMENTWe believe that patients of all ages at Bayhealth Medical Center have the right to:

• Express your pain and have that expression accepted and respected as the most reliable indicator of pain.

• Have your pain assessed systematically and thoroughly throughout all of your care.

• Have your pain managed according to the most currently accepted standards of practice throughout all of your care.

• Receive a prompt response to unrelieved pain.

• Be informed and involved in all decisions regarding all aspects of your pain care.

• Receive education regarding the management of pain side effects, treatment and options.

PATIENT RIGHTS IN PAIN MANAGEMENTAs a patient at Bayhealth, you have the right to:

• Have your reports of pain accepted and acted on by health care professionals.

• Have your pain controlled, no matter what its cause or how severe it may be.

• Be treated with respect at all times. When you need medication for pain, you should not be treated like a drug abuser.

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PATIENT RESPONSIBILITIES IN PAIN MANAGEMENTAs a patient at Bayhealth, we expect that you will:

• Ask your doctor or nurse what to expect.

• Discuss pain relief options with your doctor and nurse.

• Work with your doctor and nurse to make a pain relief plan.

• Ask for pain relief drugs when pain first begins.

• Help the doctor and nurse measure your pain.

• Tell the doctor or nurse about any pain that will not go away.

• Not worry about getting “hooked” on pain medications.

DISCHARGE INFORMATIONHow Long Will I Stay in the Hospital?We realize you do not want to be in the hospital any longer than necessary. Care Management, along with your insurance company under the guidelines of The Joint Commission, the accrediting body for Bayhealth, carefully monitors each patient’s length of stay and need for hospital services. When you and your physician agree hospital care is no longer medically necessary, arrangements will be made for your discharge. When appropriate, Social Workers will help you and your family in planning for your follow-up care.

Leaving the HospitalWhen you are discharged, please make arrangements to leave the hospital as soon as possible. Also, please be sure to take all of your personal belongings with you.

Discharge Waiting/Transitions Unit – KGH onlyKent General’s Transitions Unit is a comfortable place for patients to wait until arrangements can be made for them to return home or be transferred to another facility. Television and food services are available for your comfort and convenience.

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Discharge InstructionsYour doctor and health care team will give you written instructions about what to do after you go home. If you have any questions about your medications, activities, diet or other matters, please be sure to ask. Your instructions and any necessary prescriptions will be given to you before you leave the hospital.

Home Health CareFollowing hospitalizations, some patients need nursing care or other assistance at home in order to continue healing and to maintain an independent lifestyle. There are several agencies across Delaware offering these types of services. Bayhealth’s Home Health Care is one which provides nurses, physical therapists, occupational therapists and speech pathologists. Ask your physician if home health care is appropriate for you.

Education DepartmentBayhealth’s Education Department offers a wide variety of support groups, programs, classes and educational materials that may be of interest to you. For more information and a list of programs, please call the office at (302) 744-7135.

ADVANCE HEALTH CARE DIRECTIVEWhat is an Advance Health Care Directive? An Advance Health Care Directive is a written statement describing what medical treatments you want or do not want. It would tell your doctor what you want if you become unable to speak for yourself. An Advance Directive would go into effect only if you had a terminal condition or became permanently unconscious.

Under Delaware law, you may use either of two types of Advance Health Care Directives:

1) an individual instruction or

2) a power of attorney for health care.

An individual instruction (or “living will”) is a written statement of your wishes about health care treatment. This could include instructions to not begin or to remove life support.

A power of attorney for health care lets you name another person as an agent to make health care decisions for you if you become unable to do so. You can name any adult over the age of 18 to be your agent. However, if you are a resident of a long-term care facility, the agent cannot be an employee of the facility unless he/she is related to you.

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During the admission process, you will be asked if you have an advance directive. If so, you will be asked to provide a copy for your chart. You are not required to make an Advance Health Care Directive and your care in the hospital will be the same whether you have an Advance Directive or not.

If you want to write an Advance Health Care Directive, you must do so while you are still capable and competent to make healthcare decisions.

Who decides what health care I get? As a competent adult, you have the legal right to make your own health care decisions. You have the right to receive information about your health care and treatment options in a way that you can understand. You have the authority to say “yes” to any treatment that is offered to you, and to say “no” to most treatments that you don’t want.

What if my medical condition makes me unable to express my wishes? In Delaware, if you are at least 18 years old, you may make a written Advance Health Care Directive to accept or refuse most health care treatments or procedures if you become unable to speak for yourself.

What happens if I do not have an Advance Health Care Directive? If you become incapacitated and do not have an Advance Health Care Directive, a member of your family, who may be referred to as a “surrogate,” will be asked to make health care decisions for you. The following family members, if available, will be asked in this order: 1) spouse 2) adult child 3) parent 4) adult brother or sister 5) adult grandchild. If none of these family members are available, a guardian may be appointed by the Court.

How do I make an Advance Directive? Delaware’s “Health Care Decisions Act” includes an optional form which may be used to create an Advance Directive. If you would like to create an Advance Directive and need a form, please notify your nurse or contact any of the following:

• Bayhealth Care Management Departments: KGH (302) 744-7147, MMH (302) 430-5733

• Delaware Department of Health & Social Services, Div. Of Services for Aging and Adults with Physical Disabilities: New Castle (800) 223-9074 or Milford (302) 422-1386

• Delaware Office of the Public Guardian: (800) 464-4357

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Whether using the optional form or not, two witnesses who are at least 18 years old must watch you sign the Advance Health Care Directive. You must choose witnesses who are not members of your family, will not inherit anything from you when you die, and do not have to pay for your care.

If you are in a hospital, nursing home, or similar facility when you sign your written instruction, you must choose witnesses who are not employees of the facility.

Also, if you are in a nursing home or similar facility, one of the witnesses must be a Long-Term Care Ombudsman or the Public Guardian.

Does an Advance Health Care Directive apply when I am pregnant? Delaware law does not permit withholding or withdrawing life-sustaining measures from a pregnant patient if it is probable that the child will develop to the point of live birth with the use of life-sustaining treatment.

Where should I keep my Advance Health Care Directive? You should keep the original with other important papers and give copies to your family members, your named health care agent, your doctor and other health care providers. If you want, you can also give copies to close friends, your lawyer, or your clergyman. If you bring it to any appointment in the hospital, it can also be scanned into your universal file and will become part of your medical records which can be accessed on future admissions.

Will my Advance Health Care Directive be valid in another state? Because state laws vary widely on Advance Directives, there is no guarantee that an Advance Directive from one state will be good in another state. If you move to another state, you should make a new Advance Directive in that state. If you have a valid Advance Directive from another state, it will be valid in Delaware to the extent it is consistent with Delaware law.

Withholding or Withdrawing TreatmentAs a competent adult, it is your right to refuse further treatment should you become terminally ill. You may decide to:

• Have everything possible done to revive you if your heart or breathing stop, including CPR (Cardio-Pulmonary Resuscitation) and/or being put on a machine that breathes for you (ventilator).

• Only allow medicines to help if your heart or breathing stops. This means any IV and medication given to bring you back to life.

• Only have comfort measures. These are things like food, water, pain medication, and personal care.

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You may also decide to:

• Go home to be cared for by family and friends.

• Go home with family and the help of a visiting nurse or hospice.

• Stay in an appropriate health setting.

If you become unable to make a decision, your guardian, health care agent or family member will make decisions. If you are terminally ill or permanently unconscious, your guardian, health care agent or family member may make all health care decisions for you, including decisions to withhold or withdraw life sustaining treatment.

It is the policy of Bayhealth Medical Center to attempt to comply with Advance Directives to the extent permitted by Delaware law. A physician may decide not to act on a health care instruction for reasons of conscience. If a doctor does not want to participate in withdrawing or withholding treatment, he or she will tell the patient or family member of the objection, not interfere with transferring the patient to another physician or hospital, and continue caring for the patient until transfer is completed.

ETHICS CONSULTATIONBayhealth Medical Center’s physicians and employees are committed to serving our patients and families with the highest ethical standards. You have the right to participate in your health care decisions and to be treated with competence, care and respect. Our basic goal is to act in the best interests of our patients. Health care decisions are not always simple or easy to make. You may accept or refuse any tests or treatments that are offered or recommended. Physicians and nurses try to provide information as clearly and sensitively as possible. Decisions are often made with the help of staff and family that are based on the patient’s values and beliefs. Sometimes it may be hard to decide what choice is truly in the patient’s best interest. Sometimes, values and beliefs about proper treatments differ from person to person. Ethics consultations can be helpful in resolving these differences.

When should I seek Ethics assistance? Some people think of ethics in relation to end-of-life decisions made by or for very sick patients. However, ethical issues impact much more of day-to-day health care than people realize. Our Ethics Program can help address:

• Disagreements on health care decisions

• Decisions about Advance Directives

• Decisions about life-sustaining treatments (such as ventilators, feeding tubes, CPR, or other “heroic” measures like dialysis)

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• Questions about patient’s rights

• Questions about how to share medical information and with whom

Bayhealth Medical Center’s Medical Ethics Committee is a resource for patients, families and staff. Ethics consultations are forums for the discussion of difficult treatment decisions in an atmosphere that is nonjudgmental, supportive and respectful of the personal, cultural and spiritual values of all participants.

Education and support for those involved in the situation are provided informally as well as formally. Discussions may include patients and/or family members, primary care doctors, members of the care team such as nurses, therapists, etc. and members of the Medical Ethics Committee. For an ethics consultation, ask your physician, nurse, social worker or Patient Advocate.

How do I access the Ethics Committee for assistance? The Medical Ethics Committee is available for consultation through the patient’s physician, nurse, the Patient Advocate Department, Social Worker, Pastoral Care staff or the Administrator-on-Call.

Who is on the Medical Ethics Committee? The Medical Ethics Committee of Bayhealth Medical Center is made up of a cross-section of professionals with open attitudes, knowledge of ethical and legal standards as they apply to patient care, and the capacity for critical thinking. Experts in other areas are invited as needed for case reviews or projects.

The Ethics Program at Bayhealth Medical Center exists because conscientious individuals sometimes make different value judgments about what is best to do and that sometimes talking it out in the right setting can help.

The Ethics Program at Bayhealth also reflects our conviction that good decisions are not focused on money or sophisticated equipment, but on caring for the good of each patient.

ORGAN & TISSUE DONATIONBayhealth Medical Center participates in organ and tissue donation because transplantation can give a second chance at life.

More than 600,000 Americans could benefit today if enough organs and tissues were available. For many diseases, organ transplantation is the only accepted medical treatment to offer a chance of survival. Anyone may be a candidate for a transplant in the future, perhaps a member of your own family. Because of the great need, legislation has been enacted in many states including Delaware. Known as “Required Request,” the new laws require that hospital personnel ask each adult admitted to the hospital whether they have executed a donor card or other document of anatomical gift.

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At or near the time of a death, with the assistance of transplant program staff, hospital staff then ask family members to consider giving permission for donation. This request will give families an opportunity to consider donation. Bayhealth Medical Center supports each family’s right to have the opportunity to consider donation as an important end of life decision. Families are encouraged to discuss and understand each other’s preferences regarding donation. Families who donate report that it helps ease their own grief by helping others in great need.

The Uniform Anatomical Gift Act, now enacted in all 50 states, makes a provision for donor cards. But donor cards are not enough! The most important step in considering organ and tissue donation is a family discussion so that family members are fully informed and aware of each other’s wishes.

Some Commonly Asked Questions About Organ Donation:

What organs and tissues can be donated?The heart, kidney, liver, lungs and pancreas, as well as corneas, bone, heart valves and skin are some of the organs and tissues that can be donated to help others.

Who receives the organs and how is distribution determined?Organs are distributed to patients through a regional and national computer registry based on medical need, time on the waiting list, and the best medical match.

Are there age limits to being a donor?Everyone can be considered for organ and tissue donation. At the time of death, doctors will determine if your organs and tissues can be donated.

Is organ donation against my religion?Most major organized religions support organ and tissue donation to save lives. Please consult your clergy.

Will my medical treatment suffer if I am a donor?Many individuals fear that once they are declared donors, their own medical treatment in a hospital will suffer because their doctor will be more interested in their organs than in saving their life. This is simply not true. Organ donation is considered only after every attempt has been made to save the life of the donor.

Is there a cost to the family of the donor?There are no costs to the donor’s family for organ or tissue donation.

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Does being a donor hinder funeral arrangements?The recovery of organs and tissues for transplant is carried out in an operating room using standard surgical procedures. Following the surgery, the body is left intact and there is no disfigurement. The donation does not delay funeral arrangements nor does it prevent a normal viewing.

How do I pledge the gift of life?Sign and carry an organ donor card. (If you would like an organ donor card, please ask your nurse to contact Social Services.) Most importantly, discuss your wishes with your family.

Who do I call for more information?For more information, call the Gift of Life Donor Program, the region’s nonprofit organ and tissue transplant network at 888-DONORS-1 (888-366-6771) or 800-KIDNEY-1.

HOSPITAL BILLINGIt is in your best interest to familiarize yourself with what your insurance does and does not cover. This will help you make well-informed decisions about your health care and avoid billing and payment problems in the future. Urgent or necessary care will be given regardless of your ability to pay or insurance coverage.

A patient representative from our Patient Financial Services Department will be happy to discuss insurance and billing questions with you. You can reach a patient representative by calling Patient Financial Services Customer Service at (302) 744-7081.

Your hospital bill reflects all hospital services you receive during your stay. Charges fall into two categories: a daily room rate, which includes 24-hour nursing care, and charges for those items ordered by your physician.

The physician who treats you while you are a patient in the hospital will bill you separately for his/her services. You may also receive separate bills for professional services from other physicians, some of whom you may never actually meet, who have consulted with your physician or interpreted test results.

Although you are personally responsible for your hospital bill, Bayhealth Medical Center is pleased to accept hospitalization insurance assignment. If insurance information was not obtained prior to or at the time of admission, please make arrangements for someone to bring your insurance information and any necessary insurance forms. This information should be forwarded to the Patient Financial Services Department at the Billing Support Office (522 South State Street) in Dover or the Milford Memorial Cashier office.

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Some insurance plans may have special requirements such as a second surgical opinion or pre-certification requirements for hospital admissions. It is your responsibility to see that all plan requirements have been satisfied. Failure to do so may result in a reduction or loss of benefits, meaning you may owe more out-of -pocket expenses.

If you have no health insurance that will cover your stay, a patient representative can determine if you are eligible for financial assistance and help you by developing a fair payment plan to meet your financial obligation.

You will find a Patient Billing Guide in your discharge packet. This pamphlet will help to answer questions you may have regarding your bill.

PATIENT’S RIGHTS AND RESPONSIBILITIESBayhealth Medical Center is dedicated to providing quality medical care while preserving patients’ dignity and importance as individuals. You have the right to reasonable access to care. We consider you a partner in your hospital care. When you are well informed, participate in treatment decisions and talk openly with your doctors and other health professionals you are promoting your own safety and making your care as effective as possible. Your rights as a patient are an important element of our care for you. While you are a patient we respect your rights including the following:

Notification of Admission• To expect that a family member or representative and your physician will

be notified promptly of your admission to the hospital. Please provide your nurse with the name of the family member or representative and physician you wish to have notified.

Considerate and Respectful Care• To provide a patient centered environment and communication free from

discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. (The Joint Commission RI.01.01.01, EP 29).

• To considerate and respectful care of your personal values and beliefs, at all times and under all circumstances, provided within a safe and comfortable environment.

• To care that responds to your psychological, social, emotional, spiritual, and cultural needs.

• To have a family member, friend, or other individual of your choice to be present with you for emotional support throughout your stay unless it compromises safety or if it is medically or therapeutically contraindicated for your support person to be present. (The Joint Commission RI.01.01.01, EP 28).

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• To be informed in advance of receiving care of your rights as provided under federal and state rules and regulations.

• To know the identity of physicians, nurses, and others involved in their care, as well as when those involved are students, residents, trainees or volunteers.

• To have the opportunity to understand, discuss and request information related to specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the risks and benefits of medically reasonable alternatives (unless in an emergency where the need for treatment is urgent and you lack the ability to make decisions).

• To ask all personnel involved in your care to introduce themselves, state their role in your care, and explain what they are going to do for you.

• To be free from restraints imposed as a means of coercion, discipline, convenience or retaliation by staff.

Communication and Information about Treatment• To participate in the development and implementation of your inpatient

treatment/care plan, outpatient treatment/care plan, your discharge plan and your pain management plan.

• To have effective communication about your care and treatment.

• To obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment and prognosis.

• To obtain your informed consent before the start of a procedure or treatment (other than in a medical emergency). The physician is responsible for explaining the treatment or procedure to you or your legal representative and obtaining your consent before the start of a procedure or treatment.

• To be informed if the Hospital proposes to engage in research affecting care and to have a full explanation prior to consent. You have the right to refuse to participate and to be assured that care will not be negatively affected by such a refusal.

• To ask and be informed of the existence of business relationships among the hospitals, educational institutions, and other health care providers or payers that may influence your treatment or care.

• To be informed by your physician about outcomes of care, treatment and services provided, including unanticipated outcomes.

• To be billed only for those services provided as allowed by law and regulation. Regardless of the source of payment, you have the right to request

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a summarized list of charges and to obtain information about those charges.

Participation in Decisions about Your Care• To make decisions about care and treatment prior to and during the course

of treatment; to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy, and to be informed of the medical consequences of this action. If the refusal of treatment prevents the hospital from providing appropriate care in accordance with professional standards, the hospital and/or physician may terminate its’ relationship with you after reasonable notice and may make other arrangements for transfer, discharge or continuing care as necessary.

• To designate a decision-maker in case you are incapable of understanding a proposed treatment or procedure or are unable to communicate your wishes regarding care.

• To have family participate in care decisions or to exclude any or all family members from participating in your care decisions.

• To have help in obtaining consultation with another physician at your request and own expense.

• If you are a minor, your family and/or legal guardian will be involved in all treatment decisions for you, unless otherwise provided by law.

• To have help with learning more about your health, treatment and educational programs available to you upon discharge from the hospital.

• To be given information about realistic care alternatives when Hospital care is not indicated.

• To be cared for by staff who have been educated about patient rights and their role in supporting those rights.

• To access protective services.

• To have Bayhealth Medical Center extend these same rights, including sharing of essential information, to your legally designated decision-maker or representative if you are unable to exercise these rights.

Advance Directives• To receive written information regarding Advance Directives utilizing our

Five Wishes (Living Will instructions regarding care) and appointment of an Agent for making healthcare decisions.

• To receive assistance in making an Advance Directive.

• To expect that you will receive appropriate medical care regardless of whether you have made an Advance Directive.

• To have care at the end of life.

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• To timely information about hospital policy that may limit its’ ability to fully implement a legally valid Advance Directive.

• To provide a copy of your Advance Directive, if you have one, to be placed in your medical record.

Privacy and Security• To be interviewed, examined and treated in surroundings designed to give

reasonable visual and auditory privacy.

• To not remain disrobed any longer than necessary and to expect that staff will use privacy curtains and doors to ensure your privacy.

• To refuse to talk with or see anyone not directly involved in your care.

• To request confidential status (OPT OUT) to protect your identity as a hospitalized patient.

• To be in a safe and secure patient environment free from abuse and/or harassment.

• To have a chaperone (all patients). To be advised of the right to a 3rd party or chaperone (for minors 15 years of age or younger) to be present during certain portions of a physical examination. (Reference 24Del.C. § 1769B).

Medical Records and Confidentiality• To security, personal privacy and confidentiality of your information.

• To obtain information in your medical record while in the hospital or after discharge, or after services at one of the Bayhealth ambulatory service sites, upon request, unless such information is specifically restricted by your attending physician for medical reasons. Your medical record belongs to Bayhealth but you may request a copy of your record after discharge by contacting Health Information Services at KGH: 302-744-7041, or at MMH: 302- 430-5787. A nominal fee will be charged.

• To expect that all communication and records pertaining to your care will be treated as confidential by Bayhealth and all employees, unless you have given permission for release of information, or reporting is permitted or required by law.

• To OPT OUT of electronic information transfer to the Delaware Health Information Network (DHIN).

• To expect only the individuals directly involved in your treatment, individuals with responsibility for monitoring the quality of care, or individuals authorized by law or regulations to have access to your medical record.

• To review the medical records pertaining to your medical care and to

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have the information explained or interpreted as necessary, except when restricted by law.

Reasonable Response to Requests and Needs • To a reasonable response to the request for appropriate and medically

indicated care and services regardless of race, creed, age, sex, sexual orientation, national origin or sources of payment for care. The Hospital will provide evaluation service and or referral as indicated by the urgency of the case.

• To be transferred upon your request and/or if your condition requires a level of care not provided by the hospital. The receiving hospital and receiving physician must first accept you for transfer. In some instances, you or your family may be asked to make initial contact with the receiving physician and/or hospital.

Ethical Decisions• To express and have addressed ethical questions that arise in the course of

your care. This includes issues of conflict resolution, withholding resuscitative services, forgoing or withdrawal of life-sustaining treatment, and participation in investigational studies or clinical trials.

• To have ethical concerns brought before the Bayhealth Ethics Committee. This can be arranged through your physician, nurse, social worker, or the Patient Advocate Department.

Grievances• To voice concerns or have complaints/grievances reviewed and, when

possible, resolved. Care will not be conditioned or compromised as a result of a grievance/complaint.

• To voice a grievance/complaint using the hospital’s internal process write or call the Patient Advocate Department at KGH: 302-744-7085 or at MMH: 302-430-5126.

• To contact the following external state licensing and certification agencies if your grievances/complaints have not been resolved by Bayhealth :

• Office of Health Facilities Licensing and Certification, 258 Chapman Rd. Chopin Building Suite 101, Newark DE 19702; 302-283-7220; Fax 302-283-7221; or Hotline 1-800-942-7373.

• Unresolved quality of care and/or patient safety issues may be addressed to the Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181, 1-800-994-6610, or E-Mail: complaint@jointcommission.org

• For patients with Medicare, grievance/complaints can be addressed

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through Quality Insights of DE, at our helpline through 1-800-MEDICARE (1-800-633-4227).

• Patients with TRICARE can address grievance/complaints to: Health Net Federal Services, LLC; c/o PGBA LLC/TRICARE Grievance; P.O. Box 870150; Surfside Beach, SC 29587-9750; Fax: 1-888-317-6155; www.healthnetfederalservices.com

PATIENT RESPONSIBILITIESPatients must be aware of the hospital’s obligation to be reasonably efficient and equitable in providing care to other patients and the community. Hospital rules and regulations are designed to help the hospital meet this obligation.

Respect and ConsiderationYou are responsible for being considerate of other patients and hospital personnel by:

• Using television, telephone, radio and lights in a manner that does not disturb others,

• Honoring the confidentiality and privacy of other patients,

• Respecting the property of others,

• Reminding visitors to maintain a quiet atmosphere.

PrivacyYou or your family are responsible for giving items containing identifying information that you wish to be discarded, to your nurse, if you are concerned about the privacy of such information. The nurse will make sure these items are discarded in a manner to ensure confidentiality.

Providing InformationYou are responsible to:

• Be honest about your health and provide accurate and complete information about present and past grievances, illness, hospitalizations, medications, allergies, and other matters relating to your health.

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• Tell your doctor or nurse about unexpected changes in your condition or if you have questions or do not understand your plan of care and what is expected of you in terms of participating in your care. Please do not be afraid or ashamed to tell us when you do not understand something.

• Inform your physician and other caregivers if you anticipate problems in following the prescribed treatment.

• Let your nurse and your family know if you feel you are receiving too many visitors or telephone calls.

• Notify the Patient Advocate Department if you have a complaint or grievance or feel your rights are being violated.

Hospital ChargesYou are responsible:

• For providing complete and accurate information for payment, including insurance claims.

• Billing inquiries and questions can be addressed to the Billing Customer Service Representatives at MMH at (302) 430-5728 or KGH at (302) 744-7081.

Following Instructions• You are responsible for your actions if you refuse treatment or do not follow

the instructions of physicians or other healthcare personnel. You are responsible for keeping appointments and for giving notice if unable to do so.

Rules and Regulations• You are responsible for following hospital rules and regulations affecting

patient care and conduct and acquainting yourself with the patient handbook and safety guide.

Patient Property• You or your family are responsible for the safekeeping of valuable items

not placed in the Hospital safe. Patients are encouraged to leave or send valuables home.

Smoking • You are responsible for following and assuring that your visitors follow the

no smoking policy and state law.

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OTHER HELPFUL INFORMATIONVolunteersOur Volunteers serve an important role as Bayhealth ambassadors. You will see these men and women in various areas throughout the hospital from the Surgical Waiting Room desk, the Information Desk, taking the book cart to various floors, working in the gift shop, to even visiting patients. Most of these volunteers work a specific shift on a regular ongoing basis in a specific department. Other volunteers work on an “as-needed” basis for specific projects.

How do I obtain a copy of my medical record?Medical records are completed 30 days after discharge. There is no charge for records sent directly to a physician or other health care provider for continuing care. There is a nominal charge to obtain a copy of the records for your own usage.

To obtain a copy of your record, you must sign an authorization, which can be obtained by calling the Health Information Management at the number below. This can be done in person or mailed to the address below. Please allow two weeks for retrieval and copying.

Bayhealth Medical Center - Kent General HospitalHealth Information Management640 S. State StreetDover, DE 19901(302) 744-7038

Bayhealth Medical Center - Milford Memorial HospitalHealth Information Management P.O. Box 199Milford, DE 19963(302) 430-5787

How do I make a complaint, grievance or suggestion for improvement? We encourage you to let us know as soon as possible if there is anything we can do to make your stay more pleasant.

We value your opinion and want to know if you have a concern or grievance or would like to make suggestions for improvement. Please be assured that your care will not be conditioned or compromised by filing a concern or grievance.

Please feel free to share your concerns with the staff taking care of you. They are in the position to be able to respond to those needs immediately. There is also a house supervisor on shift 24 hours a day who can be reached by dialing “0” for the hospital operator.

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If you are not comfortable sharing your concerns directly with the staff, or wish to make a formal grievance, you can do so by contacting the Patient Advocate Department at:

KGH (302) 744-7085MMH (302) 430-5126

If you would like to send a letter expressing a compliment or a grievance, please use the following address for the hospital site where you were a patient. A patient representative will respond to you as quickly as possible.

Bayhealth Medical Center - Kent General HospitalPatient Advocate Department640 S. State StreetDover, DE 19901

Bayhealth Medical Center - Milford Memorial HospitalPatient Advocate DepartmentP.O. Box 199Milford, DE 19963

PATIENT SATISFACTION IS VERY IMPORTANT AT BAYHEALTHWhile you are a patient at Bayhealth, you may be asked a few questions about your stay.

After you have been discharged, you may receive a survey about your care. This survey will be from a research company hired by Bayhealth . The survey typically takes five to ten minutes to complete. We ask that you take the time to answer the questions and give us your feedback.

We value your input and look forward to hearing from you. Your feedback will be used to improve our current services as well as develop new services for the future.

Occasionally we also mail invitations to patients from various time periods to participate in focus groups to give us a small group look at how their hospital visit went, what we did well and areas where we could improve. If you are selected and invited, we hope you will be able to join us.

Thank you for choosing Bayhealth for your health care needs!

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FREQUENTLY CALLED NUMBERSBayhealth-Kent General Operator .....................................................(302) 674-4700Bayhealth-Milford Memorial Operator ..............................................(302) 422-3311Toll-free (Kent & Milford) ....................................................................1-888-761-8300Care Management (Social Services) KGH ..........................................................................................(302) 744-7147 MMH .........................................................................................(302) 430-5733Chaplain/Pastoral Care: KGH ..........................................................................................(302) 744-7187 MMH .........................................................................................(302) 430-5941Education ..................................................................................................(302) 744-7135Food Services – General Manager KGH ..........................................................................................(302) 744-7154 MMH .........................................................................................(302) 430-5607Food Services – Guest Trays, Tray Line KGH ..........................................................................................(302) 744-6368 MMH .........................................................................................(302) 430-5606Gift Shop KGH ..........................................................................................(302) 744-7065 MMH .........................................................................................(302) 430-5622Heath Information Management (Medical Records) KGH ..........................................................................................(302) 744-7041 MMH .........................................................................................(302) 430-5787Information Desk KGH ..........................................................................................(302) 744-6866 MMH .........................................................................................(302) 430-5620Lost & Found KGH ..........................................................................................(302) 744-6800 MMH .........................................................................................(302) 430-5100Organ Donation (Gift of Life Program) ...............................................888-366-6771 ...................................................................................................... 800-KIDNEY-1Patient Advocate KGH ..........................................................................................(302) 744-7085 MMH .........................................................................................(302) 430-5126Patient Financial Services (Billing Questions) .....................................(302) 744-7081Volunteer Services KGH ..........................................................................................(302) 744-7153 MMH .........................................................................................(302) 430-5621

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NONDISCRIMINATION POLICYAs a recipient of Federal financial assistance, Bayhealth Medical Center does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by Bayhealth Medical Center directly or through a contractor or any other entity with which Bayhealth Medical Center arranges to carry out its programs and activities.

The statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.

The Provider Name: Bayhealth Medical Center

Contact Person/Section 504 Coordinator: Jo Ann Davis

Telephone Number: (302) 744-7405

TDD or State Relay Number: Bayhealth TDD # is 1-866-237-0174.

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