2004 INNOVATIONS AWARDS PROGRAM
Application Form
(INSTRUCTIONS: Please complete and submit this document electronically if possible, e.g. a Word document. The
application form is available online at our web site, www.csg.org, in the Programs section. Please determine the appropriate
Program Category from the enclosed Program Categories sheet,
and list the category under the Category section below on the right.)
ID #: 04-S-01AR
Category: Health and Human Services
State: Arkansas
1. Program Name: ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System)
2. Administering Agency:
Arkansas Department of Human Services- Division of Medical Services and
University of Arkansas for Medical Sciences (UAMS) College of Medicine
3. Contact Person (Name and Title): Curtis Lowery, MD, ANGELS Medical Director
4. Address: 4301 West Markham, #518
Little Rock, AR 72205
5. Telephone Number: (501) 686-5986
6. FAX Number: (501) 526-7287
7. E-mail Address: lowerycurtisl@uams.edu
8. Web site Address: www.uams.edu/angels
9. Please provide a two-sentence description of the program.
Recognizing the dichotomy of obstetrical care delivery between urban and rural systems, the UAMS Department of
Obstetrics and Gynecology, in conjunction with Arkansas Department of Human Services Division of Medical
Services (Medicaid), created and developed the ANGELS program. This program, through a system of guideline
development, 24-hour/7-day week case management, and aggressive outreach education programs is designed to
improve healthcare outcomes and reduce healthcare expenditures.
10.
How long has this program been operational (month and year)? Note: the program must be
between 9 months and 5 years old on May 1, 2004 to be considered. February, 2003
11. Why was the program created? (What problem[s] or issue[s] was it designed to address?)
Several national, statewide, and local factors have influenced the direction of this program. Arkansas Medicaid is
facing severe budget cuts along with a federal mandate to increase eligibility for prenatal care from 130% to 200%
of poverty. This will increase the number of Arkansas Medicaid eligible pregnancies from 14,800 or 40% to
22,200 or 60% of deliveries annually. Presently, Medicaid is funding care for 134 medically fragile children. This
program costs $13 million annually, so if by following evidence based medical guidelines even one or two of these
poor outcomes can be averted, ANGELS would more than pay for itself. The monetary cost does not consider the
human cost of pain and suffering by the patient and family. The implementation of this program is a natural
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progression from a pre-existing statewide perinatal network. The ANGELS Program is just the beginning of how
medical care for all disciplines will be delivered in the future for the state of Arkansas.
12. Describe the specific activities and operations of the program in chronological order.
Preexisting Perinatal Network- Since 1983, a strong working relationship has developed between the majority of
the state’s prenatal providers and the UAMS Department of Obstetrics, Maternal Fetal Division. The MFM division
has created resources, programs and services to fulfill statewide obstetric providers and patients’ needs in the High
Risk Obstetrical field. The UAMS High Risk Obstetrical team includes the only board-certified MFM physicians in
the state, genetic counselors, obstetrical radiologist, diagnostic medical sonographers, neonatologists, pediatric sub
specialists, dieticians, social workers and nurses. This team of professionals is assembled together at UAMS to
accomplish the mission of providing outreach, education, research and service.
Historical and Current Obstetrical Services
With the hiring of the first Maternal-Fetal Medicine physicians in Arkansas in 1983, the Department of Obstetrics
and Gynecology has been the state leader in developing statewide, comprehensive and innovative services for sick
mothers and fetuses and outreach education for physicians. These services include the following:
Reproductive Genetics Program (1983)
High-Risk Obstetrics Program (1984)
Annual Perinatal Conference (1984)
Alpha-fetoprotein Screening for Neural Tube Defects Program (1984)
Teratogen Information Services (1986)
Fetal Boards (1989)
Medical Informatics Committee (1996)
High-Risk OB Telemedicine Weekly Case Conference (1996)
High-Risk OB and Genetics Telemedicine Clinic (1998)
ANGELS Planning 6/2002
ANGELS Implementation 2/2003
Current obstetrical services include the following:
Labor and Delivery: Recent statistics indicate that of the approximate 2,000 annual deliveries performed by the
Department of Obstetrics and Gynecology, an average of 60% is considered to be complicated or high risk. Patients
are referred from throughout the state, with Medicaid patients accounting for 46% of the obstetrical caseload.
OB Hotline: Currently, the UAMS Maternal-Fetal Medicine High-Risk OB service has a 24-hour/7days per week
1-800 Hotline number on the Labor and Delivery unit for statewide OB providers, who need acute consultations
about high-risk management or to arrange transport of complicated obstetrical cases that need higher levels of care
than can be provided locally.
Maternal Transports: Annually, there are 150 documented phone consultations and 475 OB transports originating
from the Hotline. A total of 300 will deliver at UAMS and the remainder will be treated and discharged
undelivered for further outpatient management.
Outpatient High-Risk OB Referral Service: Approximately 550 referrals are made yearly to our Maternal-Fetal
Medicine physicians through this service. The referrals are patients who have existing or new medical conditions
occurring in conjunction with pregnancy that places them in a high-risk category. Depending on the severity of
conditions, this set of patients will either be managed solely in our clinic or a plan of care will be outlined for the
referring provider to use as a guideline for managing the patient or a combined co-management plan with
alternating visits to UAMS and local providers.
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Reproductive Genetics Program: sees approximately 2,250 patients annually through their amniocentesis, genetic
counseling, high-risk ultrasound, fetal echocardiography and telemedicine clinics. These patients are referred from
around the state since the only genetic counselors in Arkansas are at UAMS.
Maternal-Fetal Medicine: In addition to the research, educational and administrative functions the Maternal-Fetal
Medicine Division performs, the Division also provides faculty support for UAMS’s Labor and Delivery and all
units that have obstetric and postpartum patients. Faculty and staff see patients in clinics at UWHC and CWC,
provide telemedicine and phone consultations and perform OB ultrasonography reading in all locations.
Continuing Medical Education: The weekly High-Risk OB Teleconference uses a complicated case for
presentation by an obstetric or family practice resident or private physician. Averages of 15 hospitals and AHECs,
with a total of 100 participants, attend each week. The Annual Perinatal Conference is a two-day conference held
each November. Along with MFM and other UAMS sub-specialists and disciplines, two out-of-state experts
present on the latest findings and developments in prenatal care. As new findings, national guidelines, or new
services develop, the MFM Division makes presentations using telemedicine. The last big push was to educate
physicians about fetal fibronectin testing to predict premature labor. The MFM team also makes presentations at
local hospitals as well as detailing visits to physician’s offices as needed. Several presentations have been made to
physicians and their nursing staff in their offices on the national guidelines for offering carrier testing for cystic
fibrosis to all prenatal patients.
Outreach and Telemedicine visits: Because the MFM Division is sold on the positive impact on high-risk
pregnancy outcomes through the use of telemedicine, the staff works closely with the Rural Hospital and
Telemedicine Program to expand telemedicine clinics to more community hospitals. An average of one visit per
week is made to local hospitals and physician’s office to discuss, plan and implement High-Risk Obstetrics
Telemedicine Clinics.
ANGELS (February 2003 start of initial implementation)
Call Center: With such a multifaceted program, and multi-points of entry, the ANGELS Consultation
Center allows the services to be stream-lined to be one point of entry system/interface with outside
providers and high risk obstetrical patients. (See attachment #1, Patient Flow Sheet.) The call center will
have the capabilities to case manage and triage obstetric and neonatal services to Medicaid’s high risk
obstetrical enrollees. The call center will have education materials, offer programs on a variety of high
risk obstetrical topics, enroll patients into the program of care, as well as perform screening assessments
for depression and smoking cessation.
Guidelines: Guidelines started being developed as soon as staff and equipment were in place. In May,
2003, the first guideline for peer review was presented over interactive video. As of April, 2004, there are
approximately 25 guidelines that have been through the peer review process.
OB and Genetics Telemedicine Clinic: Our outreach efforts have improved access to prenatal diagnosis
through telemedicine that varies from a one-time OB consult which may include an ultrasound and/or
genetic counseling over interactive video to an intensive weekly consult. These weekly consults may
include ongoing counseling, real-time detailed ultrasound for obstetric patients with high-risk problems
such as diabetes or twin-to-twin transfusion syndrome. We are currently providing weekly or bi-weekly
Telemedicine clinics to patients in six hospitals in the state (Fayetteville (2), Newport, Texarkana, Lake
Village and Hot Springs). The hospitals in Fort Smith, Batesville, Crosset, Searcy, Hope, and Stuttgart
are planned to begin OB Telemedicine clinic in May and June, 2004, respectively. Presently, up to 20
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patients are evaluated over interactive video each week. In addition to the ANGELS-specified
Telemedicine sites, other interactive video sites are available through the UAMS Rural Hospital Program
and Area Health Education Centers (AHECs) which may be used for initial ANGELS high-risk
consultations and/or continuing medical education for statewide OB care providers. (See Attachment #2
State Maps)
13. Why is the program a new and creative approach or method?
This program is an innovative program since it is a partnership between university faculty, Medicaid services, and
Department of Health. These agencies working together will serve to improve service delivery, match service with
needs, disseminate healthcare knowledge, and provide a novel approach to evaluation of outcomes. Since this
program is a contract between Medicaid and a non-profit teaching university all healthcare dollars will remain in
the healthcare system in Arkansas and can be re-invested in healthcare services.
A. This program allows physicians in the state to have peer collaboration and input into best practice guideline
development in their respective field. Formulation of the guidelines can give practicing providers a
protective barrier when practicing medicine within the guideline frameworks.
B. Equipment and personnel funded by ANGELS allows for the expansion of clinical telemedicine assisting
providers and their patients’ access to high-risk obstetrical care services locally rather than coming to
UAMS.
C. ANGELS improves and leverages other state agencies/departments to provide complementary
contributions and services. ANGELS, Arkansas Department of Health and Arkansas Department of
Human Services plan to link claims data of vital statistics to have a clearer understanding of health care
costs and evaluate relationships between maternal/neonatal outcomes. ANGELS is teaming with the
Arkansas Department of Health’s Bio-terrorism funding to place telemedicine lines and equipment into
Arkansas hospitals. This collaboration provides opportunities and benefits to all hospitals by establishing a
“Tele-medical Superhighway” without redundancy.
D. ANGELS provides the model to expand into other medical disciplines that deal with chronic illnesses such
as diabetes or heart and respiratory diseases. ANGELS will provide evidence based guidelines, case
management, and evaluation of cost effectiveness to ensure that quality of care is not compromised.
14. What were the program’s start-up costs? (Provide details about specific purchases for this
program, staffing needs and other financial expenditures, as well as existing materials, technology
and staff already in place.)
The budget in the first full fiscal year was for $4.2 million for faculty in the fields of Maternal Fetal Medicine,
Neonatology, Psychiatry, Pharmacology, Anesthesiology, Advanced Practice Nurses, Registered Nurses, Social
workers, Ultrasonographers, IT technical support, and administrative and budgetary support.
The equipment budget for this same time period was for $1.2 million. Computers, printers, scanners, case
management and triage software, telemedicine connectivity lines and equipment, ultrasound machines, and
interactive video equipment were purchased for the rural sites. The budget includes $400,000 to bring together the
evaluation team to look at targeted outcomes and what impact the program has produced. We have $300,000 dollars
budgeted for education, research, travel, communication, public relations and supplies.
15. What are the program’s annual operational costs? $9.8 million annually
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16. How is the program funded? A service contract has been put in place with the Arkansas Department of
Human Services-Division of Medical Services and University of Arkansas for Medical Sciences College of
Medicine. This contract includes federal matching funds and has oversight by the Arkansas Legislature.
17. Did this program require the passage of legislation, an executive order or regulations? No.
18. What equipment, technology and software are used to operate and administer this program?
Connectivity lines, line charges, IT support for Rural hospital sites
Interactive video equipment (Tandberg Intern II Interactive Video Unit, Tandberg 1000)
Polycom View Station
Routers, bridges to upgrade connectivity
Sonosite Titan High Resolution Ultrasound
GE Logic Book Ultrasound
ALI PACs System
ATLANTES Case Management Software
LVM Triage Software
19. To the best of your knowledge, did this program originate in your state? YES
If YES, please indicate the innovator’s name, present address, telephone number and e-mail
address.
Curtis Lowery, MD
Director of UAMS High-Risk OB Services
4301 West Markham, #518
Little Rock, AR 72205
Phone: (501) 686-5847
E-mail: lowerycurtisl@uams.edu
Judith McGhee, MD, MPH
Medical Director, Division of Medical Services
Post Office Box 1437, Slot S412
Little Rock, AR 72203-1437
Phone: (501) 682-9868
E-mail: judith.mcghee@medicaid.state.ar.us
20. Are you aware of similar programs in other states? If YES, which ones and how does this
program differ? No, in most other states, Medicaid has contracted directly with private companies which are
disease-management companies. This is the only such program that is a partnership between Medicaid, a teaching
university, and Public Health Department.
21. Has the program been fully implemented? If NO, what actions remain to be taken? Yes.
Contracts are approved, guideline development is in full swing, alliances with physicians around the state and
telemedicine delivery is active. We are in the final phase of bringing up the 24-hour/7-day week case-management
call center as well as implementing the Neonatal component.
22. Briefly evaluate (pro and con) the program’s effectiveness in addressing the defined problem[s]
or issue[s]. Provide tangible examples.
Pros of the program’s effectiveness:
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Medicaid Patients
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Insures consistency of care delivery for all Medicaid prenatal patients regardless of location or level of local
healthcare providers’ training and experience.
Accesses State’s only board-certified maternal-fetal medicine physicians, genetic counselors and other medical
sub-specialists and disciplines.
Improves clinic attendance compliance via Telemedicine Clinic.
Eliminates expense and/or inconvenience of making numerous trips to Little Rock.
Improves outcomes due to increased survival rates for inborn infants.
Prenatal Providers
 Accesses MFM consultation 24/7 through telephone call center and interactive video.
 Directs questions and referrals to one number and option of web-based intakes.
 Improves knowledge through evidence based medicine.
 Encourages input and co-management, and local care of the majority of high-risk pregnant patients.
 Uses telemedicine to keep patient in the community.
 Provides access to other medical sub-specialists.
 Decreases liability by following disease based management guidelines
Medicaid (Department of Human Services)
 Decreases morbidity of inborn infants resulting in significant cost savings.
 Provides consistent, comprehensive outcomes research data.
 Decreases costs enabling Medicaid to meet federal guidelines to cover 200% of poverty and below.
 Decreases maternal/fetal morbidity and mortality rates by facilitating access to appropriate level of care.
 Provides MFM medical expertise.
 Pilots’ use of evidence based medicine for duplication in other diseases and conditions.
University of Arkansas for Medical Sciences (UAMS)
 Proves leadership in evidence based medicine management in state over out-of-state for-profit organizations.
 Changes in-patient mix to more complex and complicated cases to match expertise of faculty and team
members.
 Expands telemedicine as a vital option for clinical services.
 Provides funding for portable ultrasound and ALI equipment for local hospitals.
 Expands UAMS mission for service, education, research and outreach.
State of Arkansas
 Maintains management of evidence based medicine in state rather than through an out-of-state for-profit
corporation.
 Increases access of care to more Arkansas residents through local hospitals.
 Expands role and viability of local hospitals by accessing sub-specialty care through telemedicine.
 Requires no additional money from the state.
 Leverages state money for federal match.
 Places Arkansas ahead of the curve nationally in implementing evidence based medicine.
Cons:
Note: ANGELS has only been in place for approximately one year. The evaluation phase of this program is
planned to begin June 2004, at which time identification of problem areas and assessment of outcomes
effectiveness will be analyzed.
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23. How has the program grown and/or changed since its inception? Little change has happened since
its inception.
24. What limitations or obstacles might other states expect to encounter if they attempt to adopt this
program?
This program is a unique partnership between University health care physicians and practicing physicians and may
not be as easily developed in other states without such a long standing history. The UAMS Department of
Obstetrics and Gynecology has had a close relationship with practicing physicians for more than 20 years. We are
the only teaching university in the state of Arkansas and we are the referral center for all high-risk obstetrics
throughout the state. This positive relationship has lead to more rapid and less confrontational adaptation of the
concept of guidelines development and case management. Guidelines are developed in conjunction with practicing
physicians through UAMS Telemedicine network. Each Thursday from 7-8am, guidelines are presented, over
statewide interactive teleconferencing. Practicing physicians review the guidelines and modifications are made as
necessary to apply to medical practice in the state of Arkansas. Essentially, we have buy-in from practicing
physicians when the guidelines are finalized.
We also do quarterly mailings of all the guidelines to healthcare providers around the state of Arkansas. In
addition, the guidelines are published on the web site. Since this program has been activated the guidelines are
rapidly becoming the standard of care for high risk Ob for the state of Arkansas. These guidelines provide
protection for physicians in the medical-legal aspects of health care delivery. Trust and frequent interactions
between UAMS faculty and practicing physicians are the keystone of this program and without this relationship it
may be difficult to roll out such a program.
Attachments:
#1 Patient Flow Sheet
#2 State Maps
Add space as appropriate to this form. When complete, return to:
CSG Innovations Awards 2004
The Council of State Governments
2760 Research Park Drive, P.O. Box 11910
Lexington, KY 40578-1910
innovations@csg.org
DEADLINE: All original applications must be received by April 20, 2004, to be considered for an
Innovations Award for 2004.
ApplicationForm04.doc
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