Background: Optimal health outcomes for newborns, especially those born prematurely, critically depend on comprehensive post-discharge care. However, healthcare systems, notably in Iran, grapple with substantial obstacles in providing effective transitional support. This study aimed to design a robust framework for the ongoing follow-up of infants after their discharge from the hospital. Methods: This strategic investigation was undertaken at Isfahan University of Medical Sciences from April ۲۰۲۲ to February ۲۰۲۴, employing a comprehensive five-stage methodology. Initially, forty-two experts in neonatal care, including specialists in pediatric nursing, were engaged through interviews to delineate existing challenges in the post-discharge continuum for preterm infants. Subsequently, the Delphi technique facilitated the prioritization of identified issues based on expert consensus. A subsequent SWOT analysis was conducted to identify internal strengths and weaknesses, alongside external opportunities and threats pertinent to current follow-up protocols. This was complemented by a Root Cause Analysis (RCA) tree diagram, enabling a detailed examination of identified contributing factors and the subsequent program formulation. The culminating phase involved the validation of the proposed program by an expert panel. Results: Four primary concerns emerged: inadequate parental empowerment concerning caregiving, deficiencies in structured post-discharge planning, limited psychosocial support for mothers, and insufficient health education for parents. The Delphi process highlighted parental caregiving and ineffective planning as paramount issues. SWOT analysis revealed systemic vulnerabilities in both maternal care provision and the follow-up service delivery infrastructure. RCA further elucidated caregiving deficits, pointing to challenges in breastfeeding education, management of post-discharge complications, impediments to maternal learning, and parental stress. Systemic shortcomings encompassed restricted access to necessary services and a high frequency of readmissions. The expert panel strongly advocated for the integration of telemedicine to facilitate program implementation. Conclusion: The devised post-discharge follow-up framework for preterm infants offers a practical blueprint for healthcare policymakers, particularly within national health ministries, to significantly enhance neonatal care, improve service accessibility, and reduce the incidence of hospital readmissions. This model underscores the indispensable contribution of pediatric nursing in ensuring a seamless continuum of care.
