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Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Nursing Evaluation01:15

Nursing Evaluation

The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.
Section...
Specialized Care Centers and Settings-II01:30

Specialized Care Centers and Settings-II

Rural Health Centers
Rural health centers are specialized care facilities in remote locations with very few medical personnel. The primary care providers who run the centers are mostly Registered Nurse Practitioners. Here, emergency treatment is provided to critically ill or injured patients before they are transferred to the closest hospital. Fortunately, due to advancement in technology, many rural healthcare facilities and professionals have easy access to diagnostic and treatment...
Restorative Care01:19

Restorative Care

Restorative care is provided once a patient has been discharged from a healthcare facility and requires additional services. The additional services include home care, rehabilitation programs, and extended care. Restorative care centers help the patient regain their previous level of functioning or acquire a new level of functioning due to the incapacitating effects of a disease or a disability. It aims to assist patients in enhancing their quality of life by encouraging independence,...
Specialized Care Centers and Settings-I01:30

Specialized Care Centers and Settings-I

Specialized care settings or centers are situated in convenient locations within the community and offer care to a specific group or population. They consist of daycare facilities, mental health facilities, rural health facilities, educational institutions, industries, shelters for the homeless, and rehabilitation facilities.
Daycare centers
They provide several functions. Some facilities care for healthy newborns and children whose parents work, while others are medically focused and care for...
Interdisciplinary Care: The Health Care Team-II01:18

Interdisciplinary Care: The Health Care Team-II

An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care. Here are a few more healthcare professionals.
Physical Therapist
A physical therapist (PT) aims to restore function or prevent additional impairment in a patient following an injury or disease. Massage, heat, cold, water, sonar waves, exercises, and electrical stimulation are some treatments used by PTs to treat...

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Updated: Jul 16, 2026

Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
19:15

Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale

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.

Healthcare (Basel, Switzerland)
|July 15, 2026
PubMed
Summary

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.

Keywords:
caregiver stresscontinuity of careintegrated caremultidisciplinary carepeer supporttelehealthtransitional carevery low-birth-weight infants

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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.