Neonatal transitional care.

Challenging times lay ahead for very low birth weight (VLBW) infants and their families after hospital discharge. Ongoing medical concerns, respiratory complications, breastfeeding and feeding problems, inadequate growth and delayed development are frequently encountered by this vulnerable population. Families are burdened by the worry and work of caring for their VLBW infants at home. Specialized support in the community is needed to help in the transition of infants and families from hospital to home. The Neonatal Transitional Care Program (NTCP) commenced in 1997 to assist homeward bound VLBW infants and their families in the Calgary Health Region. The program team, consisting of clinical nurse specialists and a dietitian, provides in-home and telephone support for four months after infants are discharged. Extensive program evaluations reveal lengthened breast milk provision, decreased demand on healthcare resources (particularly emergency departments and pediatrician offices) and enhanced maternal confidence and satisfaction with community service. In this article, the development and evaluation of the NTCP are described. This innovative approach to caring for a vulnerable population of VLBW infants and their families is believed to be the first of its kind in North America. The NTCP models neonatal care that is seamless across the healthcare system and congruent with the needs of the infant and family.