SummaryThe Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) links clinicians and patients across the state with the University of Arkansas for Medical Sciences, where virtually all of the state's high-risk pregnancy services, maternal–fetal medicine specialists, and prenatal genetic counselors are located. The program facilitates real-time telehealth consultation among patients, their local physicians, and medical center specialists through a statewide telemedicine network; develops and disseminates guidelines to foster the use of best practices by obstetric providers across the state through interactive teleconferencing; and facilitates appropriate referrals to the medical center for tertiary care through a 24/7 patient/provider call center. The program has enhanced access to specialty perinatal care, including maternal–fetal medicine consultations and tertiary level obstetric care, which, in turn, has reduced complications, generated cost savings to the State Medicaid program, and led to high levels of patient satisfaction. ANGELS has reduced Arkansas' 60-day infant mortality rate by 0.5 percent as a result of increasing the proportion of low birthweight infants delivered at the medical center.
See the Description section for information about number of guidelines and new ANGELS services; the References section for new sources of information; the Results section for updated information about consultations, guidelines, and Web site activity; the Resources section for updated staffing information; and the Use by Other Organizations section for information about program adopters (updated February 2013).Moderate: The evidence consists of before-and-after comparisons of key outcomes, including access to consultation and tertiary services, along with post-implementation satisfaction rates and cost savings estimates.
Developing OrganizationsUniversity of Arkansas for Medical Sciences
Date First Implemented2003
Race and Ethnicity > Black or African American; Vulnerable Populations > Children; Gender > Female; Age > Fetus; Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically or socially complex; Medically uninsured; Age > Newborn (0-1 month); Vulnerable Populations > Racial minorities; Rural populations; Women
Problem AddressedHigh-risk pregnancies are common in rural areas, often leading to the delivery of low or very low birthweight babies, which, in turn, increases the baby's risk of long-term health and developmental problems. Low birthweight is often the result of inadequate prenatal care,1 a shortcoming common in poor and rural areas where women have limited access to maternal–fetal medicine specialists and other specialized services.
- High-risk pregnancies and low birthweight as common problems: Approximately 40,000 children are born each year in Arkansas, with approximately 10 to 15 percent of deliveries being considered high risk. Roughly 60 percent of deliveries at University of Arkansas for Medical Sciences are classified as high risk, with one-half of these women being transported from the community setting. High-risk pregnancies often result in the delivery of low and very low birthweight babies. In fact, rates of low and very low birthweight babies in Arkansas (a poor state with many rural residents) are among the highest in the nation;2 in 2003, 8.9 percent of babies delivered in Arkansas were low birthweight (2,500 grams or less), a full percentage point above the national average.1 In 2004, this figure rose to 9.3 percent.2
- Limited health care access as partial cause: In Arkansas, 73 of 75 counties are designated as medically underserved.1 As a result, many pregnant women in Arkansas, especially those living in rural areas, have limited access to specialty prenatal care, including maternal–fetal medicine specialists.3
Description of the Innovative ActivityANGELS links patients to clinicians across the state with the medical center, where virtually all of the state's high-risk pregnancy services, maternal–fetal medicine specialists, and prenatal genetic counselors are located. The program facilitates consultation among patients, their local physicians, and medical center specialists; develops and disseminates guidelines to promote use of best practices by obstetric providers across the state; utilizes a statewide telemedicine network; and facilitates appropriate referrals to the medical center for tertiary care. Key elements of the program include the following:
- Call center: The call center, staffed by women's health registered nurses (RNs) 24 hours a day, serves as the single point of entry into the medical center obstetric services for both patients and physicians. Physicians contact the call center to arrange a telemedicine consultation with medical center maternal–fetal medicine specialists or to coordinate transport of high-risk patients to the center for care. Patients may contact the call center with questions related to pregnancy, labor and delivery, or postpartum needs. Call center services include telephone triage and advice based on ANGELS evidence-based guidelines and algorithms, referral to medical center physicians and appointment scheduling, and arrangement of emergency transportation to the center or to the nearest, most appropriate facility.
- Case management/followup care: Hospital discharge data are used to generate lists of patients to receive case management and followup care by call center RNs. In addition, medical center physicians may electronically "flag" an individual patient for followup calls at a specified time interval. RNs call postpartum patients within 24 hours of discharge and antepartum patients who have been referred to the center within 24 hours of referral. RNs continue to follow up with patients as many times as needed.
- Real-time telemedicine consultation with medical center clinical experts: ANGELS provides interactive video telemedicine equipment at no cost to approximately 25 hospital clinics and nurseries across Arkansas. Through this virtual clinic, women with high-risk pregnancies can receive real-time Level II ultrasounds, with on-the-spot consultation from ANGELS specialists. Local physicians can refer any patient for whom concerns exist. On assessment, patients with complex, high-risk conditions continue to receive ANGELS care. ANGELS empowers local providers to retain and care for their patients while simultaneously delivering the specialty expertise found at the state's only academic medical center. The majority of referrals continue to be managed locally, but patients with abnormal findings may be referred to the center for additional care or for delivery of the baby.
- Ongoing development, refinement, and distribution of guidelines: As of February 2013, the medical center Maternal–Fetal Medicine and Neonatology Divisions, in collaboration with physicians across Arkansas, has developed 101 obstetric, 55 neonatal, and 31 pediatric guidelines and protocols that encourage use of standardized best practices. Medical center clinicians review current literature and existing guidelines and then refine those guidelines to incorporate special considerations for the rural practice environment (e.g., cases in which Arkansas physicians do not have access to a recommended technology or intervention). Physicians review guidelines for discussion and refinement, with a periodic review and update based on weekly statewide teleconference discussions, Internet-based feedback forms, and formal and informal communications between community obstetricians and medical center specialists. Finalized guidelines are available on the ANGELS Web site, and DVD copies of new guidelines are distributed yearly to all obstetric providers in the state.
- Weekly provider education: ANGELS uses interactive audio/video teleconference equipment placed at 60 locations around the state to provide weekly educational conferences to interested clinicians. Sessions offer lectures, discussions of guidelines, or case presentations to help physicians across the state understand and use best practices. Sessions focus on the following types of clinical topics: high-risk obstetrics, general neonatal care, obstetric/neonatal nursing care, obstetrics/gynecology case discussions, fetal anomaly management, pediatrics, and childhood obesity. Information provided in January 2010 indicates that in 2008, ANGELS held 47 obstetric and 7 neonatal provider teleconferences reviewing evidence-based guidelines, with an average of 27 total attendees per teleconference.
- Additional services: Information provided in February 2013 indicates that ANGELS now offers the following new services:
- Secondary newborn screening: ANGELS provides secondary testing of all positive newborn screens (i.e., screening tests with a concerning result) in Arkansas. Patients with a positive secondary test are then connected with the appropriate medical team for management.
- Telepsychiatry: Telepsychiatry for women who are pregnant or postpartum was implemented in 2012. In one month, 15 patients were seen via telemedicine.
- HIV telemedicine: HIV telemedicine was implemented in 2012 to improve patient HIV care, including care for newly diagnosed women and ongoing management in pregnancy.
- Fetal diagnosis and management: ANGELS provides prenatal diagnosis and management of fetal anomalies prior to delivery, during delivery, and after birth. ANGELS ensures that the birth occurs at the appropriate care facility and provides a seamless transition between pregnancy care and intensive care for the neonate.
- Levels of care: ANGELS is leading the effort to initiate the designation of levels of care to obstetrics and neonatology in hospitals across the state. Arkansas is one of three states in the Nation to implement these levels.
- 17-Alpha hydroxyprogesterone caproate (17-P) initiative: This initiative uses telemedicine and regionalized care to provide guidelines and care for women who are at risk for preterm labor and are prescribed this medication. ANGELS is facilitating 17-P compounding in Arkansas and providing resources for rural providers to access this medication for their patients at risk of preterm delivery.
References/Related ArticlesConde JG, De S, Hall RW, et al. Telehealth innovations in health education and training. Telemed J E Health. 2010;16(1):103-6. (Added February 2013.) [Pubmed]
Hall-Barrow J, Hall RW, Burke BL. Telemedicine and neonatal regionalization of care—ensuring that the right baby gets to the right nursery. Pediatr Ann. 2009;38(10):557-61. (Added February 2013.)[Pubmed]
Kim EW, Teague-Ross TJ, Greenfield WW, et al. Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. J Perinatol. 2013; in press. (Added February 2013.)
Bronstein JM, Ounpraseuth ST, Jonkman J, et al. Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention. Health Serv Res. 2011;46(4):1082-103. (Added February 2013.) [Pubmed]
Nugent RR, Golden WW, Hall RW, et al. Locations and outcomes of premature births in Arkansas. J Ark Med Soc. 2011;107(12):258-9. (Added February 2013.) [Pubmed]
Wingate MS, Bronstein JM, Hall RW, et al. Quantifying risks of preterm birth in the Arkansas Medicaid population, 2001-2005. J Perinatol. 2012;32(3):176-93. (Added February 2013.) [Pubmed]
Ounpraseuth ST, Gauss CH, Bronstein J, et al. Evaluating the effect of hospital and insurance type on the risk of 1-year mortality of very low birth weight infants: controlling for selection bias. Med Care. 2012;50(4):353-60. (Added February 2013.) [Pubmed]
Magann EF, Bronstein J, McKelvey SS, et al. Evolving trends in maternal fetal medicine referrals in a rural state using telemedicine. Arch Gynecol Obstet. 2012;286(6):1383-92. (Added February 2013.) [Pubmed]
Bronstein JM, Ounpraseuth S, Jonkman J, et al. Use of specialty OB consults during high-risk pregnancies in a Medicaid-covered population: initial impact of the Arkansas ANGELS intervention. Med Care Res Rev. 2012 Dec;69(6):699-720. (Added February 2013.) [Pubmed]
ANGELS: Antenatal and Neonatal Guidelines, Education and Learning System. University of Arkansas for Medical Sciences. Available at: http://angels.uams.edu/
Lowery C, Bronstein J, McGhee J, et al. ANGELS and University of Arkansas for Medical Sciences paradigm for distant obstetrical care delivery. Am J Obstet Gynecol. 2007;196(6):534.e1-9. [PubMed]
Britt DW, Norton JD, Hubanks HS, et al. A two-period assessment of changes in specialist contact in a high-risk pregnancy telemedical program. Telemed J E Health. 2006;12(1):35-41. [PubMed]
Contact the InnovatorCurtis Lowery, MD
Director, ANGELS/Chair, University of Arkansas for Medical Sciences Department of OB/GYN
UAMS ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System
Department of Obstetrics and Gynecology
College of Medicine
University of Arkansas for Medical Sciences
4301 W. Markham Street #518
Little Rock, AR 72205
Rachel E. Ott
Grants Director, ANGELS
UAMS ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System
University of Arkansas for Medical Sciences
4301 West Markham, #518
Little Rock, AR 72205
Innovator DisclosuresDr. Lowery and Ms. Ott have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsANGELS has enhanced access to high-quality perinatal care, including maternal–fetal medicine consultations and tertiary obstetric care for high-risk cases, which, in turn, has reduced complications, generated cost savings, and produced a positive return on investment. ANGELS has reduced the 60-day infant mortality rate by increasing the proportion of low birthweight infants delivered at the medical center. Participating patients report high satisfaction with ANGELS and its telehealth services.
Moderate: The evidence consists of before-and-after comparisons of key outcomes, including access to consultation and tertiary services, along with post-implementation satisfaction rates and cost savings estimates.
- Enhanced access to consultations: Since the implementation of ANGELS in 2003, the vast majority of women in Arkansas live less than 60 miles from a location where they can be "seen" by a medical center expert via telemedicine. Information provided in March 2012 indicates that the number of medical center telemedicine consultations increased from less than 50 in 2000 to 3,306 in 2010; the 24/7, RN-staffed call center received and made more than 123,256 triage calls in 2010 alone, having also facilitated 619 high-risk maternal transports to the closest, most appropriate hospital. Information provided in March 2012 indicates that the number of telemedicine consultations increased to 3,866 in 2011 and that the call center made 132,239 triage calls and facilitated 541 high-risk maternal transports in 2011. Information provided in February 2013 indicates that in 2012, the number of telemedicine consultations increased to 5,221 and the call center made 148,524 triage calls and facilitated 548 high-risk maternal transports.
- Significantly enhanced access to tertiary services for women with high-risk pregnancies: Information provided in January 2011 indicates that from 2005 to 2010, 3,856 women with high-risk pregnancies and in need of tertiary care were transferred to the medical center. Many of these women would not have been transferred in the absence of the program. Among patients residing more than 80 miles from the center, the proportion of infants weighing less than 1,000 grams who were delivered at the hospital increased by 15 percent, from 40.7 percent in 2001 to 46.8 percent in 2004.1 The likelihood of a Medicaid beneficiary delivering a premature or low birthweight infant at the center (as opposed to somewhere else that is less well equipped to handle the case) has increased by 42 percent since the program began.4
- Fewer complications, leading to positive return on investment: The consultations and more specialized care provided to women at high risk has resulted in fewer medical complications, leading to savings for the Arkansas Medicaid program.
- Reduced infant mortality: ANGELS has reduced the 60-day infant mortality rate by 0.5 percent by increasing the proportion of low birthweight infants delivered at the hospital from 37.7 to 42.1 percent.
- High patient satisfaction: Patients receiving ANGELS telemedicine consultation services rate the program highly, with an average score of 4.79 on a 5-point scale.1
- Other accomplishments: Other ANGELS accomplishments include the following:
- Increase in transports: In 2010, ANGELS facilitated 619 maternal transports to the most appropriate hospital. Information provided in March 2012 indicates that in 2011, ANGELS facilitated 541 transports.
- Access to rural sites: Since 2003, ANGELS has fully equipped 38 rural sites with telemedicine technology or teleconferencing equipment.
- Guideline development: Information provided in February 2013 indicates that ANGELS has finalized 184 obstetric, neonatal, and pediatric evidence-based guidelines, which are available free on ANGELS' Web site
- Active Web site: Information provided in February 2013 indicates that the ANGELS Web site has 3,980 registrants, 2,118 within Arkansas. In 2012 alone, 4,204 people visited the Web site, of whom 1.7 percent were international visitors.
Context of the InnovationThe University of Arkansas for Medical Sciences, located in Little Rock, is one of two board-certified maternal–fetal medicine units in the state that offers specialized services for women with high-risk pregnancies, low and very low birthweight babies, and those with fetal abnormalities. The medical center, which employs the state's only three board-certified maternal–fetal medicine specialists, handled approximately 2,648 births in its 13-bed labor and delivery unit. It also has a 64-bed neonatal unit, and an additional 70 neonatal beds are located at Arkansas Children's Hospital, the pediatric hospital affiliated with the center. The medical center, the Arkansas Department of Human Services, and the Arkansas Medical Society united missions to launch ANGELS as a practice management system for perinatal care, providing the medical center with the resources needed to offer high-risk, specialty obstetric care to Arkansas' rural families. With Arkansas Medicaid oversight, ANGELS uses telehealth conferencing to reach throughout Arkansas' medically underserved areas.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Obtaining approvals from key stakeholders: The medical center collaborated with Medicaid leaders to design and formalize a care management program for obstetric care that would be covered by the Medicaid program. Program advocates also explained the ANGELS initiative to the center's senior leaders, obtaining their approval to sign a contract with Medicaid. The medical center's government relations staff and Medicaid representatives met with State legislators to explain the contract, which was later approved by the full legislature.
- Obtaining buy-in from private physicians and community hospitals: ANGELS built relationships with rural practitioners through a full-time, dedicated outreach coordinator. ANGELS' outreach efforts focused on cultivating trust and understanding of telemedicine through onsite visits to rural clinics, phone calls to maintain frequent contact, and demonstrations of telemedicine interactivity and derived benefits. ANGELS' outreach coordinator emphasized that providers would retain their patients, still serving as their primary care provider, whereas ANGELS would facilitate needed high-risk care through telemedicine and at the medical center, as needed. In finding rural telemedicine champions and pioneers in Arkansas, ANGELS met with hospital administrators, family practitioners, and obstetricians at rural hospitals and private practices. For those providers who demonstrated a genuine interest in the program, ANGELS installed telemedicine consultation equipment and began offering ANGELS services at their facility.
- Purchasing equipment: ANGELS purchases and installs telemedicine equipment at interested hospitals after a full assessment of the individual facility's technology needs. ANGELS' technologists provide full setup and training for the provided, free-of-charge equipment. ANGELS also secures equipment through grants and awards as a means to expand its partnerships.
Resources Used and Skills Needed
- Staffing: Information provided in February 2013 indicates that total staffing for the ANGELS program is approximately 82 ANGELS-paid personnel, including 4 maternal–fetal medicine physicians; 15 advanced practice nurses; 16 call center RNs; and other physicians, nurses, nurse practitioners, technologists, and other support personnel. In response to growing interest in the program, ANGELS added one maternal–fetal medicine physician in 2010. ANGELS adds to its staffing needs by paying a percentage of specialists' salaries so that they may contribute to care as needed.
- Costs: Data on program costs are unavailable. Renewing annually, the ANGELS contract dedicates the majority of funding toward the telemedicine infrastructure, equipment, and personnel required to deliver this service to rural Arkansas.
Funding SourcesUniversity of Arkansas for Medical Sciences; Arkansas Medicaid Program
- Development funding: Program development was funded by an Arkansas Medicaid contract, which evolved into ongoing programmatic support. ANGELS is also the recipient of numerous grants and awards that have allowed development and expansion of the program and its related elements.
- Ongoing funding: The Arkansas Medicaid program funds a contract for the management of patients covered by Medicaid. Program services provided to commercially insured patients are reimbursed on a fee-for-service basis. ANGELS expands its services through Federal, State, and foundation grants, which enable this program to pilot new interventions and reach new patient populations in Arkansas.
Tools and Other ResourcesANGELS guidelines are available at http://www.uams.edu/cdh1/default.asp.
Getting Started with This Innovation
- Consider a site visit: Potential adopters from across the state, Nation, and world may contact ANGELS to arrange a site visit. ANGELS' efforts in training and dissemination of its model program enabled the University of Arkansas for Medical Sciences to receive a grant award in 2010 for designation as the South Central Training Resource Center by the Health Resources and Services Administration Office for the Advancement of Telehealth. The fully equipped training center will provide online and hands-on telemedicine training to its visitors, concentrating on promoting learning in telemedicine in Arkansas, Mississippi, and Tennessee. Through this virtual and actual training center, visitors can learn about telemedicine technology and how to replicate ANGELS' innovation within their own practices. Those interested are invited to contact ANGELS for details on how the model program can be adapted to their patients' needs.
- Build relations with multiple stakeholders: Explain the program to and build relationships with insurance company representatives, university administrators, community physicians, community hospital leaders, and patients. Building relationships with community physicians is especially important, as they may feel threatened by perceived competition from the program. ANGELS has allied with other hospitals, the state's health department, community health centers, mental health centers, the state's hospital association, and other health care agencies in the effort to expand the interoperability of telemedicine networks and technology infrastructure, ensuring greater potential to meet the needs of more patients.
- Emphasize the potential for better patient care: When reaching out to stakeholders, emphasize the program's potential to improve care for patients and reduce infant mortality. Better quality of health care should be the primary goal and should take precedence over other stakeholder concerns.
- Understand the financial implications: Would-be adopters need to analyze and highlight the program's impact on hospital finances. The medical center now cares for more Medicaid patients as a result of the initiative.
Sustaining This InnovationOver its 9 years in operation, ANGELS has gained a number of valuable lessons learned that are particularly advantageous when reviewing this innovation for replication in other areas and practices. Sustaining a telemedicine system such as ANGELS requires continued efforts in fortifying existing partnerships and cultivating new collaborations, even among other agencies that may be considered competitors. Centered on the improved quality of health care and patient outcomes, sustainability efforts must merge diverse and similar organizations in the mission to expand telemedicine services into new facilities and areas. The following lessons learned offer guidance in launching and sustaining the ANGELS innovation:
- Identify available resources: Although available resources will vary, ANGELS thrives with strong intra-institutional support and legislative affairs liaisons located at the state's academic medical center, Medicaid leaders, and senators and representatives.
- Educate: To secure partnerships, each entity must learn telemedicine's medical, budgetary, and human impacts to patients and constituents. Operate within each partner's missions to guarantee buy-in.
- Illustrate cost effectiveness: After explaining how telemedicine benefits end users, explain how technology creates advantages for the partnering entity. Compare the costs of telemedicine implementation and expenses of current patient management. ANGELS explored the outcomes of late prenatal care and its ongoing costs of fragile infant management to win partners.
- Seek pilot funding: Whether through Medicaid contracts, State appropriations, Federal grants, or institutional funding, draft a budget to pilot the idea, leveraging resources wherever possible.
- Highlight successes: Keep the public aware of your services with a dedicated outreach specialist. Welcome others to visit your model program, and pursue awards, grants, and publications. With an established telemedicine infrastructure, any possibility ensues, including geographic and service-based expansion.
Additional Considerations and LessonsBecause of the program's value and potential for replication across the Nation, ANGELS was selected to be a core member of the Agency for Healthcare Research and Quality Medicaid Care Management Learning Network in 2005. ANGELS also received the 2007 American Telemedicine Association's President's Award for Innovation.
Use By Other OrganizationsInformation provided in February 2013 indicates that each month, ANGELS hosts representatives from various universities and programs who want to learn more about the ANGELS model of care. The ANGELS program has been replicated by organizations in Tennessee and Louisiana.
Lowery C, Bronstein J, McGhee J, et al. ANGELS and University of Arkansas for Medical Sciences paradigm for distant obstetrical care delivery. Am J Obstet Gynecol. 2007;196:534.e1-9. [PubMed]
Data updated January 2010 by ANGELS program developers.
ANGELS: Antenatal and Neonatal Guidelines, Education and Learning System. Letter from the Director. University of Arkansas for Medical Sciences. Available at: http://www.uams.edu/angels/letter.asp
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Service Delivery Innovation Profile
Original publication: January 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 10, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 22, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.