Implementation of a Multidisciplinary Transitional Home Care Program for Very-Low-Birth-Weight Infants: A Structured Program Evaluation

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.