Developing a Palliative Care Cancer Center in Bayamon

Victor Arroyo
Easton Ave Apartments 922
30 Easton Ave
New Brunswick, NJ 08901-1918
December 10, 2013
Carlos Blanco, MD
President of the board of directors
Doctor Center Hospital
Calle J-9, Urb. Hermanas Dávila
Bayamón, Puerto Rico 00959
Dear Dr. Blanco,
Thank you for attending my presentation of my proposal for the development of a palliative care
center for Bayamon’s Doctors Center Hospital in Puerto Rico. I hope the presentation has further
sparked your interest in my project proposal. I also appreciate our phone conversations and
discussions of the proposal; your feedback was very helpful. The final proposal now contains
accurate budget information and a relevant model of success. Attached below is a copy of my
final proposal.
Cancer is a deadly and increasingly common disease that is projected to become more common.
Cancer and cancer treatments cause pain and complication. Palliative care is becoming an
increasingly important part of treating patients. Palliative care is a medical practice that aims to
relieve physical and emotional suffering, while also improving quality of life. The development
of a palliative care center in Bayamon’s Doctors Center Hospital will provide cancer patients
with a better quality of life and care will separate Doctor's Center Hospital from other hospitals
in the area. A palliative care cancer center can attract more patients to the existing oncology
practice. It is important to have a team of professionals trained in different fields who specialize
in dealing with other factors or problems not immediately addressed by their primary medical
treatments. A strong multidisciplinary approach to the development of a palliative care center
would be beneficial not only to this growing population of cancer patients, but also the success
of your hospital.
I am writing to you because I know you have a passion to bring high quality medical care to your
community, and I believe that through the implementation of a palliative care cancer center, we
can do just that. Feel free to contact me by phone at (787)-925-9776 or by email at
varroyoru@gmail.com. If you are sending correspondence please send it to my permanent
address. Thank you for your consideration.
Sincerely,
Victor Arroyo
Victor Arroyo

The Development of Palliative Care Services for Cancer
Patients in Bayamon’s Doctors Center Hospital in Puerto Rico
Submitted by:
Victor Arroyo
Submitted to:
Carlos Blanco, MD
President of the board of directors
Doctor Center Hospital
Calle J-9, Urb. Hermanas Dávila
Bayamón, Puerto Rico 00959
December 10, 2013
Scientific and Technical Writing
Instructor: Francesco Pascuzzi
i

Abstract
Over a million people are diagnosed with cancer every year. Cancer mortality and incidents are
above average in the city of Bayamon, Puerto Rico. Cancer patients’ face many challenges,
including fighting a deadly disease and the complications that go along with their medical
treatments. Palliative care, which was once associated with terminal patients, is now being used
to treat cancer patients who suffer from pain or other problems associated with the disease or the
harsh curative treatments used to combat the disease. Many cancer patients report decreased
quality of life and increased pain during cancer treatments. Palliative care is a medical practice
that is used to relieve suffering and increase a patient’s quality of life.
Studies show that cancer patients, who receive palliative care report less pain, an increased
quality of life and even have lower mortality rates. Palliative care is a multidisciplinary practice
that includes a variety of different fields including medicine, psychology, social work, nursing
and business administration. A well trained palliative care staff provides a cancer patient with
treatment and services including: social services, pain management, physical therapy, psycho
social interventions and in some cases spiritual support. Palliative care offers multiple services
and creates multiple streams of revenue. Palliative care centers are becoming more prominent
and successful; some examples include the University of Texas MD Anderson Cancer Center
and Moffitt Cancer Center and Research Institute. Information obtained from phone interviews
with experts reflect accurate information specific to the medical practices in Puerto Rico. The
proposal outlines the development of a palliative care center for Bayamon’s Doctors Center
Hospital in Puerto Rico, which will benefit cancer patients and function as a profit generating
business.
ii

TABLE OF CONTENTS
Abstract …………………………………………………………………..……. i
Table of contents………………………………………………………….…… ii
Table of figures………………………………………………………..……….. iii
Introduction……………………………………………………………..………..1
The Prevalence of Cancer….……………………………………….……..1
Cancer and its Complications ………………………………....……...…..2
Palliative Care…………………………….…………………….......……..2
Your Role…………….………………………………………………...…..2
Research………...…………………………………………………..…………… 2
The Effectiveness of Palliative Care…………………………….……….. 2
Pain Management…..………………………………………………....….. 3
Psychological Treatment………………………………...……………….. 3
Social Work…………………………………………………....………….. 3
Other Palliative Care Services……………………..…………………….. 4
Model of Success……………………………………………………....….. 4
Specialized Palliative Care Practices…………...…….………………….. 4
Plan……………………………………………………………………………….. 5
Budget……………………………………………………………………………. 6
Fixed One-Time Expenses………………………………………...………..7
Yearly Expenses…………………………………………………..………..7
Medical Isurance………………………………………………….………..8
Overview……………………………………………………………….…..8
Discussion…………………………………………………………………...……..9
References………………………………………………………………………..10-11
TABLE OF FIGURES

Figure 1: Map of Puerto Rico Highlighting the City of Bayamon....……...………..…..……….1
Figure 2: Incidence Rate of Cancer by Municipality in Puerto Rico, 2005-2009..…………...….1
Figure 3: Incidence Rate of Lung Cancer by Municipality in Puerto Rico, 2005-2009……...….5
Figure 4: Incidence Rate of Breast Cancer by Municipality in Puerto Rico, 2005-2009…...…..5
Figure 5: Fixed One-Time Expenses for the Development of a Palliative Care Center………...7
Figure 6: Yearly Expenses for the Development of a Palliative Care Center…………………...8
Figure 7: List of Medical Insurance Providers in Puerto Rico……………………..…………...8
INTRODUCTION

The Prevalence of Cancer
The United States and Puerto Rico are seeing a significant shift in age demographics. A
combination of a 20-year increase in the average life span with decreased fertility in comparison
to the fertility spike seen after World War II is leading to a growing geriatric population above
65 years-old (CDC, 2003). Since advancing age is the number one risk factor for malignancy, it
is logical to expect an increase in prevalence of malignancies of all types. Over a million people
are diagnosed with cancer every year (American Cancer Society, 2012). Figure 1 highlights the
location of Bayamon in pink. Bayamon had a population of 208,116 people in 2010 (US Census
Bureau, 2012). In 2009 there was 12,096 new cases of cancer were reported in Puerto Rico
(Figueroa-Vallés, 2012). Figure 2 describes the incidence rate of cancer by municipality in
Puerto Rico. These incidences of cancer are most prevalent in the Puerto Rican metro area,
which includes Bayamon. Thus it is reasonable to assume that there will be an immediate
demand for high quality cancer care in Bayamon.
Figure 1
Map of Puerto Rico Highlighting the City of Bayamon
Source: (Retrieved from http://www2.luventicus.org/mapas/puertorico/bayamon.gif)
Figure 2
Incidence Rate of Cancer by Municipality in Puerto Rico, 2005-2009
Source: (Cancer in Puerto Rico, 2004-2009)
Cancer and its Complications

"Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal
cells. If the spread is not controlled, it can result in death" (American Cancer Society, 2012).
Cancer is a deadly disease that is usually treated by different methods such as chemotherapy,
radiotherapy, transplants and powerful prescription medicines. Cancer patients go through these
intense treatments which can cause a lot of pain and complications (Boyd, 2012). Some of these
symptoms include: nausea, vomiting, intractable pain, motor dysfunction, psychological
disorders such as delirium and depression, fatigue, and anorexia among others. Most of these
symptoms can be relieved or treated using a palliative care approach. Cancer in general is an
immense burden on patients and their families that can be difficult to manage without external
support.
Palliative Care
Palliative care is a medical practice that aims to relieve physical and emotional suffering, while
also improving quality of life. Although historically palliative care was associated with terminal
patients, it is currently understood that early enrollment in palliative care can prolong survival in
both terminal patients and those undergoing curative intent therapy (Temel, 2010; Otsuka , 2013)
Doctors often times recommend palliative care in addition to their curative treatment, since it can
help alleviate symptoms caused not only by the disease but also the treatment. Palliative care
treatment staff, in addition to physicians, can include: advanced practice registered nurses, social
workers, psychologists, physical therapists, occupational therapists, & chaplains (Univ. of Texas
Health Science Center). This staff can provide patients with services that can relieve pain, assist
with physical deconditioning and strength training, deal with emotional problems, provide social
services and provide spiritual support for those patients enrolled.
Your Role
As a doctor and hospital manager, you certainly understand the impact that palliative care can
have on patients. The implementation of a palliative care center for cancer patients in the
Bayamon’s Doctors Center Hospital in Puerto Rico would be the ideal location to develop the
project. A strong multidisciplinary approach to the development of a palliative care center would
be beneficial not only to this growing population of cancer patients, but also the success of your
hospital. You are an essential part of this project and this is not possible without your support
and funding.
RESEARCH
The Effectiveness of Palliative Care
Although none of the palliative care services show the ability to stop the recurrence of cancer,
they do improve a patient’s quality of life and mood (Temel, 2010; Gou, 2013; Otsuka, 2013).
Palliative care has proven to show benefits to the patients and families of cancer patients (Morita,
2013). Palliative care is becoming an increasingly important part of treating cancer patients and
is on the path of becoming a medical standard. Most major cancer hospital centers around the
world such as the University of Texas MD Anderson Cancer Center provide palliative care for
their patients. Palliative care can relieve their distressful symptoms that can possibly prevent
them from taking treatment, thus improving their chances of surviving cancer. It is important to
note that palliative care alone cannot treat a cancer patient; it is instead a complimentary
approach to be used in conjunction with the typical cancer treatment. Nonetheless, palliative care

has been proven to improve the success of cancer treatments, "it is reasonable to assume that
higher involvement in specialized palliative care services would result in the improvement in
patient outcomes" (Morita, 2012). Patients who receive palliative care have a higher chance of
survival than patients who don’t (Hanks, 2011). Palliative care today is provided by a
combination of professionals trained in different fields who specialize in dealing with other
factors or problems not immediately addressed by their primary medical treatments.
Pain Management
Pain is often a complaint for cancer patients. Doctors can prescribe both narcotic and non-
narcotic analgesics to help alleviate pain. Although in many cases patients are candidates for oral
pain medicine, some of these medicines use intravenous and intrathecal pumps, which require
specialty training to handle (Reddy, 2012). Advanced practice registered nurses (also known as
nurse practitioners) trained in cancer treatment can manage these medicines and provide the
patient with pain relief. Nurse practitioners can also make dedicated home visits as part of a
palliative care plan, where they travel to the home of patients that are bed bound and/or patients
who have transportation difficulties and provide palliative care services. This service broadens
the patient base and increases the effectiveness of a palliative care center. Advanced practice
registered nurses serve an integral part in the palliative care of cancer patient both in the center
and at the home. Cancer patients who receive palliative care report a higher quality of life and
reduced pain compared to patients who have not (Higginson, 2003). It is important for the
advanced practice nurses to understand the effects of pain medications such as opioids and how
to rotate pain medications in order to deter drug tolerance (Finnerup, 2005).
Psychological Treatment
Depression and psychological issues are common in cancer patients. "Psychosocial interventions
have been shown to be effective in reducing distress in cancer patients" (Gou, 2013).
Psychologists are also an important part of a palliative care team, since they provide counseling
for the psychological & emotional issues incurred by cancer patients and their families. It has
also been proven to be a cost effective way of providing improved quality of life as well as
physical and emotional functioning (Gou, 2013). Psychologists are also available to the families
of cancer patients, who also deal with the emotional burden of cancer. Statistically women suffer
more from psychological and emotional disturbances as a result of cancer diagnoses. This stems
from multiple factors including cancer of the breast being so prevalent as well as the cosmetic
changes associated with therapy. For this reason, this treatment should be emphasized for
women undergoing intense radiotherapy and/or chemotherapy for breast and other gynecological
illnesses (Gou, 2013). It is also beneficial to have a staff that completed workshops on cancer
patient sensitivity since it will prepare the employees to handle the difficulty of treating cancer
patients (Hanks, 2011).
Social Work
Social workers are not traditionally associated with medicine; however, in today’s hospitals and
clinics they serve an integral part in patient management. In palliative care, social workers assist
with family counseling and help aid the family with any issues or concerns the may have, which
generally includes financial support, medical insurance, placement into nursing homes or long-
term care facilities, and ultimately, even assistance with funeral services. Social workers also
provide information and can help find additional services that patients may need such as

transportation, medical power of attorney, and other social services (Reddy, 2012). The diagnosis
of cancer carries significant burden outside the medical realm and social workers help patients
and families deal with many of these problems and can ultimately help them manage their
overall situation.
Other Palliative Care Services
Other members of a palliative team can include physical therapists, occupational therapists, and
chaplains (American Cancer Society, 2012). A chaplain can provide cancer patients with
spiritual support that can give them the emotional strength to continue their medical course. In
terminal patients, the chaplain can assist with establishing goals of care and preparation for
death. Physical therapists also play an important role in the treatment of cancer patients who
often tend to suffer weakness, pain, fatigue and generalized loss of strength (Univ. of Texas
Health Science Center). Furthermore, cancer patients suffer from complications such as strokes
that can leave a patient permanently disabled. This can leave a cancer patient unable to perform
certain activities of daily living such as bathing and preparing food. Physical therapists help
patients gain their strength back and occupational therapists rehabilitate them to improve their
performance of activities of daily living (Gou, 2013). A case manager is another important
member of the palliative care team, since they help organize individual cases and help facilitate
communication between all staff members.
Model of Success
This information was obtained during a phone interview on December 7, 2013 with Cesar
Maldonado, a medical practice manager. He manages oncology practices in three different
hospitals. He told me that the Auxilio Mutuo Hospital in San Juan has a palliative care center for
cancer patients. He outlined that the success of the palliative care center is due to its location
next to an oncological practice and the lack of palliative care centers that treat cancer in Puerto
Rico. Since the implementation of the palliative care center he estimates that the oncology
practice had an increase in the number of patients by over 50%. The success was also due to the
attractiveness of the palliative services provided to the patient population. He said that with good
facilities and a quality staff a palliative care center for cancer patients could be very successful
(C. Gonzalez, Personal Communication, December 7, 2013).
Specialized Palliative Care Practices
During our phone conversations you told me that the most common types of cancer seen at the
oncology practice in Bayamon’s Doctors Center Hospital are lung cancer and breast cancer.
Figure 3 and figure 4 shows the incident rate for lung cancer and breast cancer respectively. With
lung and breast cancers being the most commonly treated types of cancer, it would seem logical
to present palliative care services specifically aimed towards them. In the case of Breast Cancer
many patients suffer from lymph node complications in their arms that can cause inflammation,
swelling and possible loss of motor function (J. Oyala, Personal Communication, November 27,
2013). A physical therapist can massage the lymph nodes of patients and ultimately reduce the
swelling in arms of patients (Hanks, 2011). Lung cancer patients that receive palliative care
report a higher quality of life. When dealing with palliative care for lung cancer patients it is
important to understand the relationship between certain drugs. Some combinations of drugs
prove to be less effective and it is important to have the training to recognize the situation and act
accordingly. Some lung cancer patients lose the ability to perform basic tasks on their own such

as eating, bathing and moving around the house (Maione, 2005). A combination of social
workers and physical therapists teach the patient how to accomplish the task with their new
limitations.
Figure 3
Incidence Rate of Lung Cancer by Municipality in Puerto Rico, 2005-2009
Figure 4
Incidence Rate of Breast Cancer by Municipality in Puerto Rico, 2005-2009
PLAN
In order to provide better care for cancer patients at the Doctor’s Center Hospital in Bayamon, I
propose the development of a palliative care cancer center that incorporates the services above
described. During our phone conversation, we discussed the availability of a 1,500 square foot
space on the seventh floor of the hospital next to the oncology ward. The fact that you already
own the space and Bayamon’s large cancer population makes this is an ideal location for the
development of the palliative care cancer center. The development of this space will have a
waiting room with a receptions desk and the construction of rooms in which patients can have

private conversations with the staff. The next steps would include furnishing the patient rooms
and waiting areas as well as recruiting the palliative care team that would include those above
mentioned. Patient rooms will require a computer and an examination table and waiting areas
would need chairs, lights, couches, and other comfortable furniture. Recruiting the diverse
professional staff will be very crucial as the human resource is possibly the most important key
to success in palliative care practice. This will include at a minimum an advanced practice
registered nurse, two social workers, two receptionists, a psychologist and a case manager. It is
very possible to outsource physical and occupational services to those already provided within
the hospital. Chaplaincy can also be provided from the current inpatient services of the hospital.
This palliative care cancer center will benefit from being on the same floor as the oncology
practice. Patients who desire to receive palliative care only have to walk down the hallway to
receive it. It is important to hire a receptionist who is positive, charismatic, and up to the
challenge of caring for such complicated patients. The receptionists will be in charge of
receiving patients, setting up appointments and helping the patients receive any information they
need. An advanced practice registered nurse, who is trained in pain management, will assess the
situation of the patient and along with the physician's recommendation develop a plan to treat the
pain, nausea, vomiting, and other organic complaints. It is important to have an advanced
practice registered nurse who is knowledgeable of the drugs used to alleviate pain and has the
ability to determine which medicines will be most effective in different situations and
complications (Boyd, 2012). I was told that in the Manati Doctors Center Hospital, which you
manage, the advanced practice registered nurses are overstaffed; moving an advanced practice
registered nurse from the Manati Doctors Center Hospital to the Bayamon Doctors Center
Hospital would be beneficial for both parties (C. Gonzalez, Personal Communication, December
7, 2013). This will also guarantee having a good quality professional employee whom you know
is properly trained and qualified. A psychologist who is trained in psychotherapy techniques
must also be hired in order to arrange and facilitate meetings with patients and their families. The
psychologist should be able to provide psychological education and support, cognitive behavioral
therapy and expressive therapy (Gou, 2013). The reason why there is only one psychologist is
because not all medical plans cover psychologist fees, and having multiple psychologists could
possibly result in making little to no profit from psychological services function (J. Oyala,
Personal Communication, November 27, 2013). The two social workers will be used to provide
social services as well as patient follow-ups. They will provide family counseling and work
towards accommodating patient’s needs. A case manager will also be hired to handle individual
cases and keep track of patients and their progress. Due to the size and scale of this project a
chaplain in this center would not be a good use of resources, but can be brought into the case
upon the patient’s request. If patients require physical rehabilitation they can be referred to the
main hospital’s rehabilitation center or brought in upon request.
BUDGET
The proposed location for the palliative care cancer center is currently unoccupied; therefore is
currently not producing revenue and carries an associated cost to the hospital. By using this
space for this project, we would be relieving the cost of vacancy associated and producing
revenue by services rendered.

Fixed One-Time Expenses
The fixed one-time expenses would stem from developing the infrastructure of the location and
the on-going cost of running the practice is driven by the personnel salaries. I was able to have a
phone interview with Jennifer Oyala on Novemeber 27, 2013. She is a public health
administrator who works for the oncology practice in Bayamon’s Doctors Center Hospital. She
was able to provide me with accurate financial information regarding Puerto Rico’s medical
system and its practices. The development of infrastructure, including: lights, tiling, painting and
the construction of rooms, is projected to cost a total of about $60,000. Furniture and supplies
will also be needed. These include desks, chairs, computers, fax, scanner, patient seating,
medical equipment. This is estimated to require $50,000. There is no need to invest in an
electronic medical record since the hospital itself has yet to implement this feature. Information
on the initial costs of the project is listed below.
Figure 5
Fixed One-Time Expenses for the Development of a Palliative Care Center
Source: (Jennifer Oyala, Personal Communication, November 27, 2013)
Yearly Expenses
Yearly expenses are composed up of employee salaries and office supplies. About $80,000 a
year are needed for office supplies. The main cost operations are employee compensation. The
average annual salary of an advanced practice registered nurse is about $35,000. Both
receptionists have an annual salary of $20,000. A case manager has an annual salary of $30,000.
Both social workers have an average annual salary of $45,000. A psychologist has an annual
salary of about $65,000. This means that your total cost will be an initial investment of $110,000
dollars in infrastructure and $340,000 in expenses per year. Physician services can be provided
by the oncology department.
Figure 6
Fixed One-Time Expenses
Inrastructure
($60,000)
Furniture ($50,000)
Total Cost:
$110,000

Yearly Expenses for the Development of a Palliative Care Center
Medical Insurance
Puerto Rico uses federal medical insurance policies from Medicare and Medicaid. These policies
usually cover 80% percent on cancer related treatments and covers 65-80% of a psychologist.
Federal insurance policies usually cover a lot of the palliative care services being offered.
However in Puerto Rico, private insurance companies are usually more restrictive. While they
cover 80% of cancer treatments they rarely compensate psychological services unless the doctor
provides reasonable justification and writes a letter to the insurance company. Physical therapy is
usually compensated 50-75% of the total cost, if there is reasonable evidence to suggest that the
complication was caused by cancer or its treatments. The fact that a lot of the services provided
in the palliative care center will be reimbursed by medical insurance companies is a good for
business (J. Oyala, Personal Communication, November 27, 2013). Examples of medical
insurance providers from Puerto Rico are listed below
Figure 7
List of Medical Insurance Providers in Puerto Rico
List of Medical Insurance Providers in Puerto Rico
Humana
Mapfre
Medical Card System (MCS)
Medical Card System Advantage
First Medical
Medicare y Mucho Mas (MMM) (Advantage)
Palic
United Health
Yearly Expenses
Supplies ($80,000)
Advanced Practice Registered
Nurse ($35,000)
Receptionist ($20,000) X 2
Social Workers ($45,000) X 2
Case Manager ($30,000)
Psychologist ($65,000)
Total:$340,000
perYear

Tricare
Triple S
Triple S Mi Salud
Overview
Building a palliative care practice carries an initial cost of infrastructure and an ongoing
operating overhead from human resource, but most importantly, this service brings a significant
amount of revenue from services provided. Palliative care services are recognized in the medical
industry and are integral in patient care. These services are reimbursed by Medicare, Medicaid,
and private insurances. Without specific patient enrollment numbers at your hospital, we are not
able to project earnings; however, palliative care services provide multiple services and as such
multiple sources of revenue. This feature combined with your high volume oncology practice
will surely provide a significant increase in revenue and given the low overhead will ultimately
yield positively to your hospitals net income.
DISCUSSION
Cancer is a deadly disease that is becoming more prevalent in our society due to advancing age.
Cancer and its associated treatments are harsh and can cause various complications. Palliative
Care is used to relieve pain and suffering from a patient. The development of a palliative care
cancer center in the Doctor's Center Hospital in Bayamon will benefit cancer patients in the area.
A well trained staff, an excellent location and this comprehensive proposal will lead to a
successful palliative care center. Patients who receive palliative care often report reduced pain,
increased quality of life and ultimately have higher survival rates than patients who don’t receive
palliative care.
I sincerely hope that my proposal has sparked your interest in the development of a palliative
care cancer center in the Doctor's Center Hospital in Bayamon. As a doctor I'm sure you can
recognize the growing importance of palliative care in cancer patients. The development of this
palliative care cancer center will help our community and will also bring profitability to the
hospital. Although there are associated initial costs, we must remember the increased revenue
and low overhead will surely make this service profitable. With your funding and support we can
make this proposal a reality.

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Palliative Medicine.

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