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Published on: August 25, 2014
Implementation of a Multidisciplinary Transitional Home Care Program for Very-Low-Birth-Weight Infants: A Structured
Chia-Wen Hung1,2, Li-Min Wu2,3
1Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan.
Insights
This study shows a multidisciplinary transitional home care program effectively supports very-low-birth-weight (VLBW) infants and their families post-discharge. The program achieved high enrollment and follow-up rates, reducing caregiver stress and improving care continuity.
Area of Science:
- Neonatal Medicine
- Pediatric Healthcare
- Public Health
Background:
- Very-low-birth-weight (VLBW) infants require specialized transitional care due to developmental immaturity and high complication risks.
- Fragmented care and caregiver burden can negatively impact adherence and infant outcomes.
- A multidisciplinary transitional home care program was developed to enhance continuity and family-centered support for high-risk infants.
Purpose of the Study:
- To describe the implementation and feasibility of a multidisciplinary transitional home care program.
- To evaluate service-level outcomes including enrollment, follow-up completion, and caregiver stress.
- To assess the program's role in supporting continuity of care and family-centered transitional support.
Main Methods:
- Retrospective descriptive program evaluation of a government-supported transitional home care program for VLBW infants.
- Multidisciplinary team provided discharge planning, risk stratification, home follow-up, telehealth, developmental monitoring, education, and psychosocial support.
- Outcomes measured by enrollment coverage, follow-up completion, developmental assessment attendance, caregiver stress, and service utilization.
Main Results:
- High enrollment coverage (97.7-100%) achieved for eligible infants.
- Significant service utilization with 3117 total encounters (video, telephone, in-person).
- High developmental assessment attendance (88-95%) and a decrease in mean caregiver stress scores (14.64 to 10.81).
Conclusions:
- The multidisciplinary transitional home care program demonstrated high enrollment and sustained follow-up engagement in a tertiary setting.
- Findings support the feasibility of integrated, family-centered transitional care models for high-risk infants.
- The program effectively enhances continuity of care and caregiver support post-discharge, though causal relationships require further study.
Abstract:
Background: Very-low-birth-weight (VLBW) infants require ongoing medical follow-up and coordinated family support after discharge due to their immature physiological development and a high risk of complications. Fragmented transitional care and caregiver burden may compromise follow-up adherence and infant health outcomes. This study aimed to describe the implementation, feasibility, and service-level outcomes of a multidisciplinary transitional home care program designed to support continuity of care and family-centered transitional support for high-risk infants through a retrospective descriptive program evaluation. Methods: Since 2022, our hospital has implemented a government-supported transitional home care program for low and VLBW infants. A multidisciplinary team provided individualized discharge planning, risk stratification, home-based follow-up, telehealth consultations, developmental monitoring, caregiver education, and psychosocial support. Program outcomes were evaluated using enrollment coverage, follow-up completion, developmental assessment attendance, caregiver stress scores, and service utilization. Results: From 2022 to September 2025, enrollment coverage reached 97.7-100% for infants ≤ 1500 g and 100% for preterm infants > 1500 g. A total of 949 video consultations and 2168 telephone or in-person follow-ups were conducted, totaling 3117 service encounters. Developmental assessment attendance rates reached 95%, 93%, and 88% at scheduled corrected-age intervals. Mean caregiver stress scores showed favorable observational trends, decreasing from 14.64 to 10.81. Fifty-two referrals to social resources enhanced service accessibility and family support. Conclusions: This multidisciplinary transitional home care program demonstrated high enrollment coverage and sustained follow-up engagement within a tertiary medical center setting. The findings support the feasibility and potential applicability of integrated and family-centered transitional care models in supporting continuity of care and caregiver support for high-risk infants after discharge. Due to the descriptive retrospective design and absence of a control group, causal relationships cannot be established.
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