Structured Post-Discharge Follow-Up

1. Post-Discharge Parent Training

Before discharge, parents are trained in essential preterm care practices including breastfeeding, Kangaroo Mother Care, infection prevention, and critical screenings such as ROP and psychosocial assessment. This equips families to safely continue care at home instead of panicking and guessing.

2. Data Capture and Community Linkage

Parent and infant details are entered into a national database immediately after discharge. Each family is assigned a Frontline Worker or Village Kangaroo Ambassador within their community, eliminating loss to follow-up.

3. Structured Home Visits for Continuity of Care

The assigned Village Kangaroo Ambassador conducts structured home visits:

• First visit within 48 hours of discharge
• Ongoing growth and developmental monitoring
• Feeding and Kangaroo Care support
• Early identification of danger signs
• Vaccination reminders and clear referral pathways
• Digital tracking and alert systems for timely intervention

This is not casual visiting. It is scheduled accountable follow-up.

4. Clinic Follow-up and Referral System

Parents attend scheduled clinic reviews where healthcare providers assess progress, manage complications, and initiate referrals when needed. Community and facility care work as one loop not two disconnected systems.

5. Continuous Community Support

Frontline Workers maintain regular contact with families, reinforcing care practices, troubleshooting challenges, and ensuring no child falls through the cracks after discharge.