UAMS IDHI High-Risk Pregnancy Program

Evidence-level

Evidence-Based (About evidence-level criteria)

Description

Arkansas has many rural communities with high poverty and limited access to specialized maternal-fetal medicine. This lack of access to prenatal care can result in high-risk pregnancies and low birthweight babies.

Since the program's beginning, there has been an increase over time in the number of preterm babies delivered in hospitals with appropriately staffed neonatal intensive care units, which increased better outcomes for low birthweight babies.

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 IDHI High-Risk Pregnancy Program (formerly known as ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System). This program enhances rural women's access to care by linking patients across the state with physicians and high-risk pregnancy services at UAMS.

Services offered

The High-Risk Pregnancy Program connects patients and clinicians throughout Arkansas with specialists at UAMS clinics. Specifically, the program provides:

• Evidence-based guidelines: Guidelines are developed and disseminated to promote best practices for obstetric and neonatal providers.
• Outreach, education, and support for OB providers: This includes teleconferences, OB/GYN grand rounds, and other specialty groups.
• 24/7 Consultation Call Center: A 24-hour call center staffed by registered nurses (RNs) offers consults, triage, transport, follow-up, appointment scheduling, referrals, and provider support.
• Case management: This is done through programs such as the Following Baby Back Home program, Telenursery Program, and Arkansas Fetal Diagnosis and Management.
• Expansion of telemedicine network and clinics: This is done over a statewide telemedicine network.
• Evaluation and research: Activities include presenting at conferences and other events, applying for grants, and writing/submitting publications.

The High-Risk Pregnancy Program educates providers through:

• Statewide COVID-19 teleconferences for providers regarding COVID-19 best practices
• 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
• POWER (Prenatal Outcomes Workgroup using Education and Research), which works with hospital teams to address barriers to evidence-based practice and decrease maternal morbidity and mortality throughout Arkansas. Currently, POWER is working to implement maternal safety bundles for hypertension, postpartum hemorrhage, and postpartum racial and ethnic disparities in hospitals throughout the state.
• Fetal monitoring courses, offered both online and face-to-face by the Outreach Education Team
• Neonatal Resuscitation Program (NRP) courses

Here are other programs that have become part of the program's arsenal of healthcare tools:

• OB Simulation fulfills educational and training needs of healthcare professionals through obstetric simulations and drills.
• The Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional (S.T.A.B.L.E.) Program is the most widely distributed and implemented neonatal education program, and it educates and trains licensed healthcare professionals working in neonatal critical care.
• Arkansas Fetal Diagnosis and Management (AFDM) is a multidisciplinary program for pregnant individuals and their families who have been given a diagnosis of a fetus with a congenital anomaly or genetic disease.
• The Perinatal Opiate Project provides evaluation and individual treatment plans for opiate dependency during pregnancy.
• The Angel Eye program allows parents to watch, take photos of, and speak to their infant in real time from any computer when the newborn is in the intensive care unit.
• Telenursery conducts nursery census and weekly rounds with 26 of the state's outlying hospital nurseries and provides neonatal and subspecialty education, consultations, follow-up, and back transport of infants to their local hospital and community.
• A statewide newborn screening program provides physician consultations, education, and secondary testing support for expanded newborn genetic testing.
• WIN (Web-Based Instruction on Nutrition) provides maternity nutrition education.
• Diabetes Care in Pregnancy (via telemedicine or face-to-face) is provided by the UAMS Obstetrical Center for Management of Hyperglycemia in Pregnancy.

Results

The program has enhanced access to specialty care for rural individuals in Arkansas and has resulted in:

• Decreased distance that many individuals in Arkansas have to travel to be seen by an obstetric expert via telemedicine by equipping over 30 rural sites with needed technology and using the patient's home as a place of service
• Development of more than 170 obstetrical and neonatal guidelines for rural providers
• An increase in Medicaid beneficiaries delivering premature or low birthweight babies at facilities with appropriately staffed NICU services
• Fewer complications for high-risk individuals and their babies
• Cost savings for Arkansas' Medicaid program due to fewer complications
• Over 3,200 telemedicine visits in fiscal year 2023 for expectant mothers
• Over 1,800 tele-ultrasounds conducted in fiscal year 2023
• Over 380 high-risk OB consults in fiscal year 2023
• Over 118,600 calls answered, with 6,654 nurse triage calls in fiscal year 2023
• 198 back transport to rural hospitals in fiscal year 2023 for mothers and infants who delivered at urban facilities but could be clinically managed nearer home
• Over 180 tele-fetal-echocardiography visits in fiscal year 2023

From 2022 to 2023, 106 patients reported on their satisfaction with services:

• 95% of patients reported they were happy with their telehealth visits
• 95% of patients found that their providers usually or always explained things in a way that was understood
• 81% of patients said scheduling their telehealth appointment was easy
• 60% of patients said they liked telehealth services since they were not required to "travel to the telehealth appointment"
• 5% said they liked telehealth services since they "did not have to find someone to take care of their kid(s)"
• 48% of patients traveled less than 30 miles to attend their telehealth appointment
• Over 48% would have had to travel over 70 miles from home if telehealth weren't an option
• The self-reported savings is between $75 to $150 per visit

A provider survey that received over 500 responses revealed:

• 100% of providers agreed that "I would use [the] services again if needed" or "[The] services are important for the state of Arkansas"
• Over 97% of providers reported that services are "excellent"
• Transportation is a key barrier to receiving care; traveling to Little Rock is a "major venture for most people, so they come to us where we can utilize telemedicine"

The program 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 (AHRQ) Medicaid Care Management Learning Network in 2005. The program contributed to the designation of UAMS as the South Central Telehealth Resource Center by the Health Resources and Services Administration (HRSA) and to the designation of UAMS as an HRSA Telehealth Focused Rural Health Research Center.

For more detailed information on the program's results:

Sung, Y-S., Zhang, D., Eswaran, H., & Lowery, C.L. (2021). Evaluation of a Telemedicine Program Managing High-Risk Pregnant Women with Pre-Existing Diabetes in Arkansas's Medicaid Program. Seminars in Perinatology, 45(5), 151421. Article Abstract

Rhoads, S.J., Eswaran, H., Lynch, C.E., Ounpraseuth, S.T., Magann, E.F., & Lowery, C.L. (2018). High-Risk Obstetrical Call Center: a Model for Regions with Limited Access to Care. The Journal of Maternal-Fetal & Neonatal Medicine, 31(7), 857-865. Article Abstract

Bronstein, J.M., Ounpraseuth, S., & Lowery, C.L. (2020). Improving Perinatal Regionalization: 10 Years of Experience with an Arkansas Initiative. Journal of Perinatology, 40(11), 1609-1616. Article Abstract

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. Article Abstract

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., Williams, D.K., Kuo, D., & Hall, R.W. (2013). Telemedicine Collaboration Improves Perinatal Regionalization and Lowers Statewide Infant Mortality. Journal of Perinatology, 33(9), 725-730.

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 Birth Weight Infants: Controlling for Selection Bias. Medical Care, 50(4), 353-360.

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).

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.

Bibliography of articles

Challenges

This program overcame implementation barriers by identifying "telemedicine champions" in rural communities, in most cases family practice or obstetrical providers who advocated for the use of the program's 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 telemedicine will actually enhance local care, creating an environment of co-management for complex patients.

To the extent possible, the program's 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 the program 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.

Replication

This program and its evaluations show the importance of reaching out to rural providers to encourage referrals. One 2012 study found that while referrals to programs like it 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 the High-Risk Pregnancy Program to include providers, health departments, and other key stakeholders in the planning and design of interventions in order to increase their acceptance of and participation in such programs.

As a Telehealth Resource Center, UAMS provides telemedicine training to organizations within the south central region of the United States to replicate the High-Risk Pregnancy Program and other telemedicine interventions in their communities. The High-Risk Pregnancy Program hosts other programs and universities at the training center. You can contact the program to learn more.

Contact Information

Joseph Sanford, MD, Director
UAMS IDHI High-Risk Pregnancy Program
jasanford@uams.edu