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UAMS IDHI High-Risk Pregnancy Program

Summary 
  • Need: Arkansas had high rates of low birthweight babies, and pregnant individuals in rural areas had difficulty accessing specialty obstetric care.
  • Intervention: The University of Arkansas for Medical Sciences created the IDHI High-Risk Pregnancy Program to increase access to care for pregnant individuals in an effort to improve outcomes for high-risk pregnancies.
  • Results: The program has increased access to care and reduced infant mortality for rural Arkansas individuals through a variety of programs and has been recognized by various organizations as a model 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. 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 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 the University of Arkansas for Medical Sciences.

To learn more about this program, you can watch this 3-minute video:

Services offered

The High-Risk Pregnancy Program 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

The High-Risk Pregnancy Program also 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) 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
ANGELS Obstetric, Neonatal, Pediatric Image

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.
  • STABLE 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 a genetic disease.
  • Perinatal Opiate Project provides evaluation and individual treatment plans for opiate dependency during pregnancy.
  • HIV management for pregnant individuals 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.
  • Tele-nursery 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.
  • Tele-lactation provides additional support for a breastfeeding mother.
  • 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. The program 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 40 rural sites with needed technology
  • Development of 175 obstetrical and neonatal guidelines for rural providers
  • 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 individuals and their babies
  • Cost savings for Arkansas' Medicaid program due to fewer complications
  • 0.5% decrease in 60-day infant mortality rate
  • Over 2,600 telemedicine visits in 2019 for expectant mothers
  • Over 1,900 tele-ultrasounds conducted in 2019
  • Over 400 high-risk OB consults in 2019
  • Over 161,000 calls answered, with 9,906 nurse triage calls in 2019
  • 275 back transports to rural hospitals in 2019 for mothers and infants who delivered at urban facilities but could be clinically managed nearer home

Between 2018 to 2019, 39 patients reported on their satisfaction with services:

  • 96% 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
  • 87% of patients said scheduling was largely considered
  • 60% of patients said they liked telehealth services since they were not required to "travel to the telehealth appointment"
  • 11% said they liked telehealth services since they "did not have to find someone to take care of their kid(s)"
  • 50% of patients traveled less than 30 miles to attend their telehealth appointment
  • Over 60% would have had to travel over 70 miles from home if telehealth weren't an option
  • The self-reported savings of this is between $75 to $150 per visit

A recent provider survey that polled 84 physicians revealed:

  • 100% of providers agreed that "I would use ANGELS services again if needed" or "ANGELS 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.

You can learn more about the program by reading its annual reports and newsletters.

For more detailed information on the program's results:

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), 1609-16. 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 from 2014 and older

Challenges

This program 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 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 the telemedicine provider will 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, Interim Director
UAMS IDHI High-Risk Pregnancy Program
jasanford@uams.edu

Topics
Maternal health and prenatal care
Telehealth
The South
Women

States served
Arkansas

Date added
December 28, 2010

Date updated or reviewed
November 17, 2020

Suggested citation: Rural Health Information Hub, 2020. UAMS IDHI High-Risk Pregnancy Program [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/681 [Accessed 28 October 2021]


Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.