ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System
- Need: Arkansas had high rates of low birthweight babies, and women in rural areas had difficulty accessing specialty obstetric care.
- Intervention: The University of Arkansas for Medical Sciences created the ANGELS telemedicine program to increase access to care for pregnant rural women in an effort to improve outcomes for high-risk pregnancies.
- Results: ANGELS has increased access to care and reduced infant mortality for rural Arkansas women through a variety of programs and has been recognized by various organizations as a model program.
Evidence-Based (About evidence-level criteria)
Arkansas has many rural communities with high poverty and limited access to specialized maternal-fetal medicine. According to the Arkansas Department of Health, 73 of the 75 counties in the state are designated as medically underserved. This lack of access to prenatal care can result in high-risk pregnancies and low birthweight babies. In 2003, 8.9% of the babies delivered in Arkansas had low or very low birthweights.
To improve access to care and the health of newborn babies, the University of Arkansas for Medical Sciences (UAMS) implemented a statewide telehealth program called the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS). This program enhanced rural women's access to care by linking patients across the state with physicians and high-risk pregnancy services at the University of Arkansas for Medical Sciences.
ANGELS connects patients and clinicians throughout Arkansas with specialists at the University of Arkansas for Medical Sciences clinics. Specifically, the program provides:
- Guideline development and dissemination to promote best practices for obstetric providers
- A statewide telemedicine network for consultations with medical experts
- Referrals to tertiary and/or emergency care at UAMS
- A 24-hour call center staffed by registered nurses (RNs)
- Follow-up home care for families of high-risk infants through the Following Baby Back Home program
ANGELS also educates providers through:
- Peds PLACE, a weekly pediatric educational conference for clinicians across the state through the use of teleconferencing
- ONE Team, to allow nurses a chance to earn continuing education units via telemedicine
- High-Risk Obstetrics Case Teleconferences, which provide a collaborative forum to join healthcare providers across Arkansas to develop best practice guidelines for selected conditions
- OB/GYN Grand Rounds Teleconferences, which provide physicians and other medical professionals the opportunity to present clinical and research topics relating to OB/GYN and women's primary healthcare
- FAIM Teleconferences, to review a variety of congenital anomalies including new management and treatment techniques
- DISCOVER MCH Leadership, which delivers distance learning opportunities through interactive video and web-based materials to encourage interdisciplinary participation and pursuit of continuing education units, exploring topics specific to the Mississippi Delta's racial, ethnic, and cultural needs
Here are other programs that have become part of the ANGELS' arsenal of healthcare tools:
- OB Simulation fulfills educational and training needs of healthcare professionals through obstetric simulations and drills.
- STABLE educates and trains nurses working in neonatal critical care.
- Arkansas Fetal Diagnosis and Management (AFDM) is a multidisciplinary program for pregnant women with a diagnosis of a fetus with a congenital anomaly or a genetic or chromosomal abnormality.
- Women's Mental Health Consultation Services provides telepsychiatry for pregnant or postpartum women across Arkansas in person or through teleconferencing.
- Perinatal Opiate Project provides evaluation and individual treatment plans for opiate dependency during pregnancy.
- HIV management for pregnant women is available.
- Diagnosis via telemedicine of fetal abnormalities and care is available as needed.
- The Angel Eye program allows parents to watch, take photos, and speak to their infant in real time from any computer when the newborn is in the intensive care unit.
- A telecolposcopy program provides guidance in colposcopic evaluations and conservative follow-up of low-grade lesions for a safe and cost-effective means of managing abnormal Pap smears.
- A project called "TOUCH" provides telemedicine connectivity to eight hospital labor and delivery departments in Arkansas to UAMS, allowing for real-time reporting and tracking for high-risk mothers transported.
- Telenursery conducts nursery census and weekly rounds with 26 of the state's outlying hospital nurseries.
- A statewide newborn screening program provides physician consultations, education, and secondary testing support for expanded newborn genetic testing.
- Anesthesia/C-Section Pre-Op Clinic serves to connect UAMS anesthesia physicians to pre-op obstetric patient sites across the state to prepare for UAMS delivery.
- WIN (Web-based Instruction on Nutrition) provides maternity nutrition education.
- POWER (Prenatal Outcomes Workgroup using Education and Research) works with hospital teams to address barriers to evidence-based practice and decrease maternal morbidity and mortality throughout Arkansas.
ANGELS has enhanced access to specialty care for rural women in Arkansas. The program has resulted in:
- Decreased distance that many women in Arkansas have to travel to be seen by an obstetric expert via telemedicine by equipping 44 rural sites with needed technology
- Development of 247 obstetric, neonatal, and pediatric guidelines for rural providers
- 12,957 nurse triage calls in 2016
- 575 high-risk maternal transports in 2016
- Increase in Medicaid beneficiaries delivering premature or low birthweight babies at the UAMS (versus at a hospital less equipped for the special needs of the mother and baby)
- Fewer complications for high-risk women and their babies
- Cost savings for Arkansas' Medicaid program due to fewer complications
- 0.5% decrease in 60-day infant mortality rate
ANGELS was honored with the American Telemedicine Association's President's Award for Innovation in 2007 and its Institutional Award for Advancement of Telemedicine in 2011. The program was also a core member of the Agency for Healthcare Research and Quality Medicaid Care Management Learning Network in 2005. ANGELS contributed to the designation of UAMS as the South Central Telehealth Resource Center by the Health Resources and Services Administration (HRSA).
For more detailed information on ANGELS' results:
Rhoads, S.J., Green, A., Mitchell, A., & Lynch, C.E. (2015). Neuroprotective Core Measure 2: Partnering with Families-Exploratory Study on Web-Camera Viewing of Hospitalized Infants and the Effect on Parental Stress, Anxiety, and Bonding. Newborn and Infant Nursing Reviews, 15(3), 104-110.
Hughes, D.S., Ussery, D.J., Woodruff, D.L., Sandlin, A.T., Kinder, S.R., & Magann, E.F. (2015). The Continuing Antenatal Management Program (CAMP): Outpatient Monitoring of High-Risk Pregnancies. Keeps Patients Safe, Costs Low and Care Nearby. Sexual & Reproductive Healthcare, 6(2), 108-109.
Lowery, C.L., Bronstein, J.M., Benton, T.L., & Fletcher, D.A. (2014). Distributing Medical Expertise: the Evolution and Impact of Telemedicine in Arkansas. Health Affairs (Millwood), 33(2), 235-243. Article Abstract
Long, M.C., Angtuaco, T., & Lowery, C. (2014). Ultrasound in Telemedicine: its Impact in High-Risk Obstetric Health Care Delivery. Ultrasound Quarterly, 30(3), 167-172. Article Abstract
Kim, E.W., Teague-Ross, T.J., Greenfield, W.W., Keith, W.D., Kuo, D., & Hall, R.W. (2013). Telemedicine Collaboration Improves Perinatal Regionalization and Lowers Statewide Infant Mortality. Journal of Perinatology, 33(9), 725-730. Article Abstract
Ounpraseuth, S., Gauss, C.H., Bronstein, J., Lowery, C., Nugent, R., & Hall, R. (2012). Evaluating the Effect of Hospital and Insurance Type on the Risk of 1-Year Mortality of Very Low Birthweight Infants: Controlling for Selection Bias. Medical Care, 50(4), 353-360. Article Abstract
Magann, E.F., Bronstein, J., McKelvey, S.S., Wendel, P., Smith, D.M., & Lowery, C.L. (2012). Evolving Trends in Maternal Fetal Medicine Referrals in a Rural State Using Telemedicine. Archives of Gynecology and Obstetrics, 286(6), 1383-1392. Article Abstract
Bronstein, J.M., Ounpraseuth, S., Jonkman, J., Fletcher, D., Nugent, R.R., McGhee, J., & Lowery, C.L. (2012). Use of Specialty OB Consults during High-Risk Pregnancies in a Medicaid-Covered Population: Initial Impact of the Arkansas ANGELS Intervention. Medical Care Research Review, 69(6), 699-720. Article Abstract
Wingate, M.S., Bronstein, J., Hall, R.W., Nugent, R.R., & Lowery, C.L. (2012). Quantifying Risks of Preterm Birth in the Arkansas Medicaid Population, 2001-2005. Journal of Perinatology, 32(3), 176-193. Article Abstract
Bronstein, J.M., Ounpraseuth, S., Jonkman, J., Lowery, C.L., Fletcher, D., Nugent, R.R., & Hall, R.W. (2011). Improving Perinatal Regionalization for Preterm Deliveries in a Medicaid Covered Population: Initial Impact of the Arkansas ANGELS Intervention. Health Services Research Journal, 46(4), 1082-1103. Article Abstract
Nugent, R., Golden, W.E., Hall, W., Bronstein, J., Grimes, D., & Lowery, C. (2011). Location and Outcomes of Premature Births in Arkansas. The Journal of the Arkansas Medical Society, 107(12), 258-259. Article Abstract
Lowery, C., Bronstein, J., McGhee, J., Ott, R., Reece, E.A., & Mays, G.P. (2007). ANGELS and University of Arkansas for Medical Sciences Paradigm for Distant Obstetrical Care Delivery. American Journal of Obstetrics and Gynecology, 196(6), 534.e1-9. Article Abstract
ANGELS overcame barriers of adoption by identifying "telemedicine champions" in rural communities, in most cases family practice or obstetrical providers who advocated for the use of ANGELS telemedicine services within their local hospital.
These champions are essential for success, as some providers may fear that the telemedicine practice will infringe on their local practice. The telemedicine champions can act as trusted agents to demonstrate that the telemedicine provider will enhance local care, creating an environment of co-management for complex patients.
To the extent possible, the ANGELS telemedicine model seeks to keep the patient in the care of their local provider, except when it is necessary for the patient to see a specialist face-to-face. Having a community telemedicine champion combined with a strong program outreach component was essential for ANGELS to show community providers that their practice would be enhanced by telemedicine, not replaced by it.
Telemedicine champions are also essential in navigating local or organizational barriers, helping establish relationships with local technologists, and managing community relations that impact program adoption.
This program and its evaluations show the importance of reaching out to rural providers to encourage referrals to ANGELS. One 2012 study found that, while referrals to programs like ANGELS almost doubled for Medicaid recipients between 2001 and 2006, rates of referrals still varied widely among providers. It is important for agencies wishing to replicate ANGELS to include providers, health departments, and other key stakeholders in the planning and design of interventions in order to increase their acceptance and participation in such programs.
As a HRSA Telehealth Resource Center, UAMS provides telemedicine training to organizations within the south central region of the United States to replicate ANGELS and other telemedicine interventions in their communities. ANGELS hosts other programs and universities at the training center. Any group wishing to learn more about the adaption of this program should contact ANGELS to learn more.
Curtis L. Lowery, MD
ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System
Children and youth
Prenatal care and obstetrics
December 28, 2010
August 4, 2017
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