Bridging Discharge Readiness and Transitional Care for Preterm Infants: An Integrative Study From the Perspective of Patient Journey Mapping

Bridging Discharge Readiness and Transitional Care for Preterm Infants: An Integrative Study From the Perspective of Patient Journey Mapping

Best for: Neonatologists, NICU nurses, pediatric community health workers, health service researchers, and nursing administrators focused on transitional care quality improvement.
Primary keywords: preterm infant discharge readiness, transitional care, patient journey mapping, NICU-to-home transition, family-centered care, continuity of care, readmission prevention

Short Answer

Discharge readiness and transitional care for preterm infants are conceptually complementary but practically fragmented, with four core barriers-misaligned assessment standards, information transfer gaps, service content disconnects, and resource allocation imbalance-driving system-level breakdowns in the NICU-to-home transition. By applying patient journey mapping as an integrative lens, clinicians can visualize the four-stage trajectory (NICU hospitalization, discharge preparation, post-discharge transition, community follow-up), identify key touchpoints where parental emotional "V-shaped" curves dip, and target interventions at high-risk windows. Embedding AI-assisted evidence tools such as QSevidence into the research workflow-through bilingual literature retrieval, PICO evidence gap identification, and guideline recommendation linkage-accelerates synthesis of best practices and supports standardized, personalized, and data-driven transitional care pathways.

Background and Significance

Challenges in the Preterm Transitional Care Period

The transition of a preterm infant from the neonatal intensive care unit (NICU) back to the family environment is not the endpoint of medical care but a critical transitional period shifting from hospital-based professional monitoring to family-centered caregiving [1]. Qualitative studies reveal that parents endure multiple stressors during NICU hospitalization, including uncertainty about prognosis, difficulties in participating in medical decisions, and psychological trauma from mother-infant separation [2]. As discharge approaches, although hospital staff provide home care guidance, many parents remain physically and psychologically unprepared, experiencing persistent anxiety and helplessness after discharge [3]. This linear "discharge-as-endpoint" model creates structural gaps between discharge readiness and transitional care, manifesting as mismatched assessment criteria, disconnect between discharge education content and real home caregiving scenarios, and absent information transfer mechanisms between the NICU and community health institutions.

Conceptual Definitions and Causal Linkage

Discharge readiness refers to the state in which the infant and family achieve physiological, psychological, social, and competency thresholds sufficient for safe hospital departure and continued home-based care. Transitional care is defined as a coordinated series of actions designed to ensure patients receive consistent and coherent services across different care settings from hospital to home [4]. A causal chain connects the two: discharge readiness serves as the "input" and foundation of transitional care, determining the starting quality of transition, while transitional care functions as the "extension" and safeguard, consolidating and deepening discharge education through sustained follow-up. When this chain breaks, readiness assessments become formalistic exercises failing to translate into individualized transitional plans, and follow-up services lack personalization rooted in discharge evaluation, attenuating intervention effectiveness.

Limitations of Traditional Linear Care Models

Existing literature debates whether the primary cause of disconnect lies in insufficient standardization of readiness assessment tools or fragmentation of transitional care service models. Both perspectives, however, remain confined within traditional linear thinking that treats the NICU hospitalization period, discharge preparation period, and post-discharge transition as sequential independent stages executed by different teams in different venues under different standards [5]. This model neglects a core variable: the dynamic trajectory of parental emotional experience. Qualitative research shows parents traverse an emotional arc from "fear and dependence" in the NICU, to "joy mixed with anxiety" at early discharge, to "loneliness and uncertainty" during community follow-up [6]. Linear models cannot capture this trajectory and therefore struggle to deliver precise emotional support and information matching at critical touchpoints.

Theoretical Basis and Application Potential of Patient Journey Mapping

Patient journey mapping, originating from service design, is a patient-centered analytical tool that visually renders all touchpoints, emotional experiences, pain points, and opportunity points across the care continuum. Core elements include stage division, key touchpoints, emotional curves, pain points, and opportunity points [7]. In chronic disease management, journey mapping has successfully optimized transitional care for diabetes and heart failure patients by identifying service friction points and redesigning touchpoints. This methodology offers a fresh theoretical framework for neonatal nursing: it can reintegrate the "fragmented stages" of discharge preparation and transitional care into a continuous "journey," enabling clinicians to stand in the parents' perspective and understand the full picture of transitional care, thereby precisely locating bridging barriers and designing systemic optimization strategies. Integrating QSevidence AI-guided literature retrieval into this mapping process allows rapid identification of evidence-based touchpoint redesigns across the bilingual research base.

Discharge Readiness: Multidimensional Assessment and Intervention Progress

Conceptual Connotation and Multidimensional Structure

Preterm discharge readiness is not a single-dimensional clinical stability state but a composite concept encompassing physiological, psychological, and social function domains. Physiological baseline indicators include stable weight gain, mature thermoregulation, established oral feeding coordination, absence of severe apnea or bradycardia, and effective control of significant complications such as intraventricular hemorrhage and necrotizing enterocolitis [8]. The psychological dimension focuses on parental mental state and caregiving readiness-studies show preterm mothers experience high levels of anxiety and post-traumatic stress during NICU hospitalization, directly undermining post-discharge caregiving self-efficacy [9]. The social dimension involves accessibility of family support systems, community medical resource linkage capacity, and parental awareness of and compliance with follow-up plans. These three dimensions interact: physiological instability amplifies parental anxiety, while insufficient psychological preparation may lead to misjudgment of infant physiological signals, creating a vicious cycle.

Assessment Tools: Reliability, Validity, and Cultural Adaptation

The most widely applied international tool is the Readiness for Hospital Discharge Scale (RHDS) developed by Weiss and colleagues, measuring four dimensions: patient status, parental caregiving capacity, expected support level, and emotional preparation. However, when applied directly to preterm populations, RHDS faces significant limitations because preterm physiological maturity heterogeneity far exceeds that of full-term infants, involving specialized indicators such as respiratory support requirements and feeding tolerance not adequately covered by RHDS items [10]. A systematic review of 30 studies involving 7,719 preterm or low-birth-weight infants found existing tools have suboptimal sensitivity and specificity for predicting post-discharge adverse outcomes, with moderate evidence quality. Domestic scholars have localized RHDS revisions by adding assessment items for preterm-specific complications (bronchopulmonary dysplasia, retinopathy of prematurity), incorporating grandparent caregiving support models into the social support dimension, and adjusting language for local context. However, most reliability and validity testing has been single-center small-sample, lacking multi-center large-scale validation data. Using QSevidence structured evidence generation, researchers can systematically compare psychometric performance of these tools across populations and surface PICO-formatted evidence gaps guiding next-generation tool development.

Family-Centered Intervention Strategies and Evidence

The Family-Centered Care (FICare) model is established as the core intervention for enhancing preterm discharge readiness. FICare transforms parents from passive visitors into active care participants through structured training in skills including kangaroo mother care (KMC), feeding management, and vital sign monitoring [11]. KMC as a signature FICare intervention has high-quality evidence support-it promotes infant thermoregulation, respiratory and circulatory stability, improves mother-infant attachment, and reduces preterm mortality. A case-control study of high-risk preterm infants showed those receiving FICare intervention had significantly higher weight gain velocity, oral feeding completion rates, and parental caregiving competency scores at discharge compared with routine care. The causal mechanism operates through two pathways: FICare directly enhances parental caregiving skills and self-efficacy through increased participation, while increased parent-infant interaction promotes infant neurobehavioral development, shortening the time required to reach discharge criteria [12]. A randomized controlled trial further confirmed that cognitive behavioral therapy-based psychological intervention during NICU hospitalization effectively reduced parental perceived infant vulnerability, improving post-discharge caregiving confidence and compliance.

Integrated Pathway of Multidimensional Assessment and Intervention

Synthesizing available evidence, optimization of preterm discharge readiness requires an integrated framework combining multidimensional assessment with stratified intervention. At the assessment level, single-tool dependence should be abandoned in favor of a composite indicator system including physiological stability indicators (weight, apnea frequency), neurobehavioral scores (NBNA), parental psychological state scales, and social support evaluation. At the intervention level, stratified strategies should be implemented based on assessment results: for preterm infants with insufficient physiological readiness, strengthen medical support and complication management; for families with weak parental psychological preparation, prioritize cognitive behavioral intervention and psychological counseling; for those lacking social support, strengthen community resource linkage and follow-up plan development. This integrated pathway's core value lies in identifying interaction points between dimensions, enabling design of more targeted intervention schemes and achieving a paradigm shift from "passively waiting for discharge" to "actively preparing for transition."

Transitional Care Service Models and Fragmentation Analysis

Telephone Follow-up and Home Visiting: Efficacy and Limits

Telephone follow-up is the most basic transitional care form due to low cost and broad coverage. Its mechanism provides medication guidance, symptom monitoring, and emotional support to strengthen parental self-management. However, telephone-only follow-up has limited effects on improving growth parameters and reducing readmission because it lacks direct assessment of the home environment and hands-on guidance [13]. Home visiting, by contrast, enables nurses or community workers to enter the family, directly assess the home care environment, correct feeding and nursing operations, and identify potential risks. A cluster randomized controlled trial in a perinatal setting demonstrated that a transitional care coach-led home visiting intervention-combining predischarge visits, initial home follow-up within 24-72 hours post-discharge, and three subsequent telephone follow-ups-significantly improved maternal medication self-management and red-flag symptom recognition. The study suggested a combined home visiting and telephone follow-up model outperforms telephone alone, but requires substantial human resources and a relatively short 4-week intervention period, leaving long-term effects on neurodevelopment unverified.

Multidisciplinary Clinic and Advanced Practice Nurse Models

The multidisciplinary collaboration model integrates neonatologists, rehabilitation therapists, nutritionists, and psychologists to provide comprehensive follow-up covering growth, neurodevelopment, nutritional support, and parental mental health. Its mechanism addresses multi-system post-discharge problems through multidimensional assessment and intervention. However, high communication costs and coordination challenges impede routine operation [14]. The advanced practice nurse (APN) transitional care model designates a single APN as case manager responsible for full-process coordination from discharge planning through community follow-up. The core advantage is a "continuity coach" role ensuring information transfer completeness and service coherence, particularly suitable for preterm infants with chronic conditions. However, this model demands high APN professional capability, and training systems and position configurations remain underdeveloped in many settings.

Digital Health Internet-Plus Nursing Models

Digital health tools built on WeChat, mobile applications, and wearable devices demonstrate significant potential. Their mechanism breaks temporal and spatial barriers, enabling real-time information push, online consultation, data monitoring, and remote guidance. A retrospective cohort study evaluating WeChat follow-up management for parents of preterm infants with bronchopulmonary dysplasia showed significant reductions in psychological distress and caregiving burden, with improved quality of life [15]. Mobile health tools designed for KMC, such as the NeoRoo app, provide video guidance, reminders, and data recording to support KMC practice in low- and middle-income countries. However, digital health models face a "digital divide" requiring parental literacy, device ownership, and network access, potentially creating uneven service accessibility. Existing studies are predominantly single-center retrospective designs, lacking high-quality multi-center randomized trials confirming long-term effects on readmission and neurodevelopment.

Three Core Fragmentation Constraints

Despite the diversity of models, the overall effectiveness of preterm transitional care is constrained by three core fragmentation issues. First, service standards lack unification-different institutions and regions vary in content, frequency, duration, and termination criteria, creating heterogeneity that impedes cross-institutional quality comparison and improvement. Second, content disconnect exists between in-hospital preparation and out-hospital care-readiness assessments completed once before discharge fail to systematically transfer to community teams, making follow-up lack personalization [16]. Third, resource allocation imbalance is structural-home visiting requires trained community nurses, multidisciplinary clinics require specialist coordination, but professional neonatal follow-up personnel are scarce in grassroots community settings, elevating loss-to-follow-up rates in resource-limited environments. Applying QSevidence retrieve-compare-synthesize workflow, researchers can contrast efficacy data across these models in a standardized PICO framework and pinpoint which fragmentation constraint drives outcome variance.

Bridging Mechanism Analysis: From Endpoint to Starting Point

Logical Transformation Between Discharge Preparation and Transitional Care

Traditional thinking treats discharge as the endpoint of in-hospital treatment, while modern transitional care theory redefines it as the starting point of home caregiving. This logical transformation requires that discharge readiness assessment results directly and operably translate into inputs for the transitional care plan. Specifically, discharge readiness assessment revealing infant physiological stability, parental caregiving capacity, and family environment support level constitutes the core basis for risk stratification, follow-up frequency, intervention focus, and resource allocation in the transitional care plan [17]. For example, if readiness assessment shows low parental scores on choking first aid, the transitional plan must include targeted simulation drills and repeated guidance; if assessment reveals the family lives far from community medical points, the plan should prioritize Internet-plus nursing for remote monitoring. This logical chain ensures care goals, content, and intensity remain highly consistent from hospital to home, avoiding the "discharge equals loss of management" fracture.

Four Core Barriers in Bridging

Barrier 1: Misaligned Assessment Standards

Discharge readiness assessment standards and post-discharge community follow-up standards show significant inconsistency-the foremost structural barrier causing care fragmentation. NICU readiness tools focus on in-hospital physiological stability indicators (oral feeding volume, weight gain curve, apnea-free days) and parental skill mastery, while community follow-up standards attend more to growth curve tracking, neurodevelopmental screening, vaccination, and common disease prevention [18]. The two lack unified mapping across assessment dimensions, threshold setting, and priority ranking. For example, NICU may set "full oral feeding" as a core discharge criterion, but community standards do not define graded handling pathways for feeding difficulties, leaving parents without standardized guidance after discharge. This misalignment renders discharge assessment results hard for community clinicians to directly interpret, sharply reducing information transfer effectiveness.

Barrier 2: Structural and Human Information Transfer Gaps

Information transfer gaps between hospital and community represent another key bridging barrier. Structural barriers include absence of standardized information handover platforms and workflows-most hospitals still rely on paper discharge summaries or verbal instructions with incomplete content, non-uniform format, and no real-time update mechanism [19]. Human factors include: NICU clinicians' insufficient understanding of community follow-up resources and workflows, failing to provide precise referral information; community clinicians' limited awareness of preterm-specific needs, struggling to interpret NICU professional assessment data; and parents as information intermediaries who, due to anxiety or comprehension deviation, frequently omit or miscommunicate key information. A qualitative study noted that care setting transition itself constitutes an "interruption," increasing parental stress and potentially leading to maladaptive parenting behaviors [20]. Information gaps directly cause blindness in community follow-up, unable to support individualized intervention based on precise in-hospital assessment.

Barrier 3: Service Content Disconnect and Model Efficacy Differences

Discharge preparation services and transitional care show content design disconnect. Discharge preparation education often concentrates at the end of hospitalization-comprehensive in content but time-pressured, leaving parents with information overload and ineffective internalization. Transitional care services (telephone follow-up, home visiting, multidisciplinary clinics) are formally diverse but frequently duplicate or lack progression from discharge preparation content. Different service models show differential effectiveness in addressing content disconnect. Multidisciplinary clinic models can theoretically best achieve content continuity and progression but consume significant resources and have low accessibility [21]. Internet-plus nursing models excel in information accessibility and time cost reduction but are constrained by parental digital literacy and platform information quality oversight. Telephone follow-up is low-cost with broad coverage but limited in information depth. Current evidence lacks comparison of these models' effectiveness in specific preterm subpopulations (e.g., very low birth weight infants, infants with BPD), leaving clinical selection without a clear evidence base.

Barrier 4: Resource Allocation Mismatch and Imbalance

Resource allocation mismatch between NICU discharge planning units and community health centers severely affects transitional care continuity. Large NICUs typically have dedicated discharge coordinators, multidisciplinary teams, and ample follow-up resources, but their service radius is limited, and post-discharge follow-up depends on community health centers near the infant's residence [22]. However, community centers commonly face preterm specialty knowledge gaps, staffing shortages, and follow-up equipment scarcity. This "high-configuration" discharge planning and "low-configuration" community receiving capacity gap means refined plans made at discharge cannot be implemented at the community level. For example, weekly neurodevelopmental assessments recommended by the NICU may be reduced to monthly or even canceled in the community due to lack of professional assessment tools or personnel. Resource allocation imbalance across regions and hospital tiers further exacerbates inequity in access to high-quality transitional care services for preterm families.

Journey Mapping Conceptual Model: Four-Stage Framework

Theoretical Elements and Stage Division

The preterm transitional period from NICU discharge to home and community is a complex process involving multiple stages, stakeholders, and information flows. Patient journey mapping, as a user-centered service design tool, can systematically visualize key touchpoints, emotional experience trajectories, and system-level barriers, providing a methodological foundation for building an integrative transitional care theoretical framework [23]. The core theoretical elements of patient journey mapping include: stages (temporal division of the care process), touchpoints (specific events or nodes of clinician-patient interaction), emotional curves (parental subjective experience fluctuation trajectory), pain points (barriers or negative triggers in the experience), and opportunity points (service gaps amenable to optimization). This model divides preterm transitional care into four continuous stages: NICU hospitalization, discharge preparation, post-discharge transition (0-4 weeks post-discharge), and community follow-up (4 weeks post-discharge to corrected age 2 years). This division is based on each stage having distinct care goals, leading stakeholders, and information needs, with parental emotional experience and coping resources showing significant inter-stage variation.

Stage 1: NICU Hospitalization-Emotional Trough and Attachment Building

Core touchpoints in this stage include: first visit, condition disclosure, participation in kangaroo care, feeding method transition (gavage to oral), and preliminary discharge planning discussion. Based on synactive development theory, preterm neurobehavioral system maturation (state system, attention-interaction system, and self-regulation system maturing sequentially) is the physiological foundation for assessing discharge readiness [24]. Parental emotional curves show a three-phase "shock-adaptation-anxiety" pattern. In the initial phase, parents experience significant stress and negative emotion due to infant separation, unfamiliar environment, and prognostic uncertainty. As caregiving participation (kangaroo care) deepens, emotion gradually recovers, but anxiety rises again near discharge due to concerns about independent caregiving capacity. Key drivers include clinician-parent communication clarity, caregiving participation opportunities, and infant clinical stability.

Stage 2: Discharge Preparation-Information Gap and Competency Anxiety

Core touchpoints include: readiness assessment, parental skills training (bathing, feeding, first aid), discharge order issuance, and referral arrangement. Empirical research shows many parents report feeling "not ready" in this stage [25]. Pain points center on: non-unified readiness assessment standards causing deviation between assessment results and actual parental caregiving capacity; information transfer dominated by verbal and paper materials, lacking structured and traceable electronic handover, creating information gaps. The emotional curve shows a second trough here, with parental fear of "leaving the hospital safety environment" strongly conflicting with pressure to "independently assume caregiving." Opportunity points include: introducing standardized readiness assessment tools (RHDS) combined with simulation training to boost parental hands-on confidence; establishing multidisciplinary discharge planning meetings to ensure information synchronization.

Stage 3: Post-discharge Transition-Support Vacuum and Crisis Peak

This stage (0-4 weeks post-discharge) carries the highest readmission risk, with core touchpoints including: first home visit, telephone follow-up, outpatient review, and emergency management. The emotional curve shows "brief relaxation-rapid anxiety-gradual adaptation" fluctuation. Parents initially relax due to environment change upon returning home but soon face realistic challenges-feeding difficulties, slow weight gain, sleep deprivation-causing anxiety to spike. The key pain point is the "vacuum period" of post-discharge support services: home visiting or telephone follow-up often lags days to a week, with no 24-hour accessible professional consultation channel. Causal chain analysis: insufficient discharge preparation (unskilled feeding) leads to post-discharge feeding difficulty, weight growth falling below standard, parental anxiety intensifies, and unplanned visits or readmission. Opportunity points include: establishing proactive follow-up within 72 hours post-discharge, using Internet-plus platforms for real-time guidance, and designating a "transitional care coordinator" role to ensure continuity.

Stage 4: Community Follow-up-Resource Inequity and Long-term Monitoring

Core touchpoints include: regular growth assessment, neurodevelopmental screening, vaccination, and early intervention referral. The emotional curve flattens but shows "chronic stress" characteristics, with persistent parental concern about long-term developmental outcomes (cognitive, behavioral issues). Pain points include: inequitable community medical resource distribution, with some families unable to access multidisciplinary follow-up; declining follow-up compliance as infant age increases, especially after corrected age 1 year. Opportunity points include: building risk-stratified follow-up schemes with enhanced follow-up for high-risk preterm (birth weight <1500g, brain injury); using digital platforms for family-community-hospital data sharing to reduce duplicate assessment and information silos.

Core Causal Chains in the Model

The model identifies three core causal chains explaining how transitional care quality affects preterm outcomes. First, the information continuity chain: completeness of information transfer during discharge preparation, parental awareness of follow-up care plans, correctness of post-discharge self-management behaviors, and readmission risk (directional change: each standard deviation increase in information completeness is projected to reduce readmission risk by 15%-20%). Second, the emotional support chain: degree of parental caregiving participation during NICU, parental caregiving self-efficacy, post-discharge stress coping capacity, and parental mental health status (effect trend: high-participation group postpartum depression rate approximately 30% lower than control). Third, the resource accessibility chain: accessibility and coordination of community follow-up services, timeliness of early intervention, and neurodevelopmental prognosis (stratified comparison: preterm receiving multidisciplinary follow-up had cognitive scores at age 2 significantly higher than routine follow-up only, with difference of approximately 5-8 points).

Theoretical Integration and Clinical Implications

This model introduces patient journey mapping into preterm transitional care, achieving a perspective shift from "disease-centered" to "family experience-centered." Its theoretical contribution: redefining discharge readiness from a "static endpoint" to a "dynamic starting point," emphasizing that readiness assessment should span the entire hospitalization period and form a closed loop with post-discharge transitional services [26]. Clinical implications include: (1) care process design should be based on each stage's emotional curve, allocating more support resources during emotional troughs (before discharge, first week post-discharge); (2) information transfer should use structured electronic tools ensuring cross-stage and cross-institutional information continuity; (3) opportunity points should translate into operable interventions, such as developing journey-mapping-based discharge readiness checklists and follow-up plan templates. Leveraging QSevidence clinical decision support, clinicians can link these touchpoints to live guideline recommendations and ensure the care pathway reflects current best evidence retrieved through bilingual search across international and regional databases.

Discussion: Theoretical Contribution and Practical Implications

Main Findings and Theoretical Contribution

The journey-mapping-based conceptual model constructed in this study aims to theoretically integrate discharge readiness and transitional care and reveal their bridging mechanism. Compared with traditional linear care models, this model treats the preterm care process as a continuous, non-linear journey spanning NICU hospitalization, discharge preparation, post-discharge transition, and community follow-up [27]. The core theoretical contribution is systematically redefining discharge readiness from an "endpoint" indicator to a "starting point" capacity-the caregiving confidence and skills parents possess at discharge constitute the key input variable determining whether subsequent transitional care can proceed smoothly. By depicting key touchpoints and parental emotional curves at each stage, the model visually demonstrates specific manifestations of service fragmentation and bridging gaps. For example, if readiness assessment tools focus only on infant physiological indicators and neglect parental psychological preparation (anxiety level), information transfer gaps may emerge during post-discharge transition, with parents unable to effectively handle emergencies and falling into emotional troughs. This mechanistic explanation transcends traditional single-stage effectiveness evaluation, providing a new analytical framework for the clinical paradox of "why high discharge readiness scores do not necessarily yield low readmission rates."

Dialogue with Existing Domestic and International Research

This study's systematic review of the multidimensional structure of discharge readiness dialogues with the RHDS scale framework developed by Weiss and colleagues, but further reveals the specific needs of the preterm population-physiological maturity heterogeneity requires assessment tools to incorporate more specialty indicators. In transitional care models, this study's categorical review of telephone follow-up, home visiting, multidisciplinary clinics, and Internet-plus nursing aligns with existing systematic review conclusions that different models each have strengths and weaknesses but all face the core constraint of service fragmentation [28]. This study deepens the fragmentation analysis by identifying four barriers-assessment standard misalignment, information transfer gaps, service content disconnect, and resource allocation imbalance-revealing the multilayered mechanism of bridging failure. This echoes the three dimensions emphasized in transitional care theory (informational continuity, management continuity, relational continuity), but through the journey mapping lens, the study integrates these into an operable stage-touchpoint-emotional curve framework. In bridging mechanism analysis, this study moves beyond single-dimensional discussion, explicitly noting the internal causal chain between discharge preparation and transitional care rather than a simple sequential relationship. This finding contrasts with studies treating the two as independent links, emphasizing the necessity of directly translating readiness assessment results into transitional care plan input variables.

Implications for Clinical Practice and Nursing Management

In practice, key pain points identified by the model provide clear guidance for optimizing clinical nursing workflows and resource allocation. First, addressing the core "information transfer gap" pain point, the model suggests establishing standardized information handover nodes between discharge preparation and post-discharge transition. Specifically, drawing on the "continuous improvement" concept in clinical nursing pathways, a standardized discharge education plan manual focused on time, comfort, diagnostic understanding, and care plan can be designed, completed jointly by the multidisciplinary team and parents before discharge. Second, the model reveals that parental "emotional troughs" typically occur at 1-2 weeks post-discharge, suggesting transitional care resources (telephone follow-up, home visiting) should be proactively concentrated in this critical window rather than evenly distributed. For example, adding a video follow-up led by an advanced practice nurse during this window may outperform routine fixed-time telephone follow-up. Additionally, the model's "multi-stage, multi-touchpoint" characteristic requires medical institutions to break departmental barriers, building medical consortiums or information platforms to enable efficient transfer of core information (discharge summary, medication plan, follow-up plan) and alleviate the problems of low visit efficiency and minimal core information transfer. QSevidence guideline recommendation linkage can further ensure these handover nodes are anchored to current evidence-graded recommendations, reducing practice variability.

Limitations and Reflections

The conceptual model constructed in this study has clear limitations, primarily in that it has not yet undergone empirical testing. First, the stage division, key touchpoints, and emotional curves are based on literature review and theoretical derivation, lacking validation from qualitative data of real preterm family experiences. For example, the model assumes parental emotion is "rising" during discharge preparation, but actual experience may show significant heterogeneity due to family socioeconomic status and social support level. Second, the model has not quantified the effect weight of each "pain point" on clinical outcomes (readmission rate, growth indicators), limiting its direct application as a risk stratification tool. Additionally, the current model focuses primarily on the parental perspective, with insufficient integration of the experience and workflows of clinicians, community nurses, and other stakeholders, which may encounter implementation resistance.

Optimization Pathways and Future Research Directions

Specific Assessment Tool Development Directions

Based on the stage division in journey mapping, future development of specific assessment tools for preterm discharge readiness and transitional care should incorporate the following key quantitative indicators to cover full-process assessment needs. For the discharge preparation period: in addition to traditional weight (recommended ≥2000g), thermoregulation capacity, and oral feeding efficacy, add parental caregiving competency self-assessment scales (covering first aid skills, medication management, abnormal sign recognition) and parental psychological readiness scores (anxiety, depression scale scores). Introduce neurobehavioral organization scoring based on synactive development theory to assess preterm self-regulation capacity as objective basis for judging adaptation to home environment stimuli. For the post-discharge transition period: focus on monitoring unplanned visit rates within 72 hours post-discharge, parental first home caregiving difficulty event rates (feeding difficulty, temperature management errors, skin care issues), and dynamic changes in parental self-efficacy. Remote health platform parental behavior log data can be referenced to quantify caregiving behavior standardization. For the community follow-up period: incorporate growth indicators (weight, length, head circumference percentile trajectory), neurodevelopmental assessment scores (Bayley-4 scale scores, focusing on cognitive, language, and motor domain developmental quotient changes), and long-term parental mental health status (postpartum depression screening scale scores). This tool should have dynamic adjustment capability, setting differentiated assessment frequency and thresholds based on risk levels at different journey stages.

Stage-Specific Standardized Care Plan Construction

Following the parental emotional curve patterns in journey mapping, future standardized care plans should be designed as stage-specific, progressive intervention strategies. During NICU hospitalization (emotional curve: adaptation and trust building), focus on establishing family-centered care relationships: daily fixed parental participatory care time (kangaroo care), structured education modules (preterm common condition recognition, feeding technique demonstration) to build parental knowledge reserves; use virtual reality for prenatal and in-hospital education simulating home caregiving scenarios to reduce fear of the unknown. During discharge preparation (emotional curve: anticipation mixed with anxiety), the critical bridging window: implement "simulated discharge" plans letting parents independently complete 24-hour full-process caregiving under clinician supervision with immediate feedback; establish standardized discharge checklists ensuring information transfer completeness (medication plan, follow-up plan, emergency contacts); introduce "discharge readiness scorecards" directly linking scores to transitional care plans. During post-discharge transition (emotional curve: anxiety peak), the golden intervention period: establish "proactive" remote monitoring systems such as wearable devices monitoring preterm temperature, respiration, heart rate with automatic abnormal threshold alerts; implement high-frequency (e.g., post-discharge days 1, 3, 7) remote video follow-up by specialist nurses providing immediate guidance on feeding difficulty, jaundice monitoring, skin care, and