Abstract
The Baby Steps program, a nurse-led telehealth transition of care intervention for infants cared for in the neonatal intensive care unit (NICU) and their caregivers, was developed to address a gap in care after discharge. The program focused on providing integral support during the discharge process and after the infant returned to home and community. Led by an interprofessional team composed of researchers, NICU professionals, and telehealth specialists, the program was guided by the Theory of Transition Model to support the situational, developmental, and health transitions that occur during this time period. Central to the intervention was nurse-led telehealth follow-up within 24–48 h after discharge, coupled with on-demand services available for 2 weeks. During these encounters, a trained NICU nurse offered clinical support, addressed concerns, and provided anticipatory guidance. Within the first 24 months of the program, a total of 450 infants were enrolled, and 492 total encounters were completed. Significant decreases in readmissions were noted (57%). Additionally, caregivers reported a high level of satisfaction, with 99.2% reporting they were satisfied or highly satisfied (n = 141). In conclusion, we found that nurses effectively counseled caregivers, and that the use of telehealth intervention after discharge was feasible.