Parent experiences of a remote patient monitoring program enabling early discharge from the neonatal intensive care unit with nasogastric tube feeding

Abstract

BACKGROUND:

This exploratory study examined parents’ experiences with “Growing at Home” (G@H), a remote patient monitoring program for stable infants discharged from the Neonatal Intensive Care Unit (NICU) with continued need for nasogastric tube feeding.

METHODS:

We used classical content analysis to identify and refine emergent themes from 13 semi-structured key informant interviews.

RESULTS:

The primary emergent theme was the desire to return to normalcy, which was expressed as a primary motivator for participating in G@H. Parents reported G@H assisted them in transitioning from the NICU’s highly medicalized setting to establishing a new normal with incorporation of their infant into their lives and families. Parental preparation is important, as some parents experienced challenges that indicate the program may not be suitable for all families.

CONCLUSIONS:

Parental experiences offer insight into benefits and challenges of early discharge from the NICU and highlight opportunities to support families beginning in the NICU and as they transition home.

Keywords

Early NICU discharge home nasogastric tube feeding parent perspectives qualitative interviews remote patient monitoring

1 Introduction

Premature infants admitted to the neonatal intensive care unit (NICU) are not typically deemed appropriate for discharge until they have met physiologic criteria, including cardiorespiratory stability, temperature regulation, and ability to take full feeds by mouth with weight gain [1]. This final criterion is often the remaining barrier to discharge for infants who are premature or who have other medical issues, despite otherwise being medically ready for discharge. In the past, infants have typically remained admitted until they reach full oral feeds or have received gastrostomy tubes [1]. However, literature on programs that allow infants to be discharged with nasogastric (NG) tube feedings is growing and indicate that these programs are safe and effective without increases in readmissions [2 –5].

Benefits of programs facilitating early discharge have included increased breastfeeding rates [6, 7], shorter hospital stays [3 –5], hospital cost savings [4], parental empowerment [8, 9], and provision of family-centered care [8, 9]. These programs typically utilize a combination of nurse home visits and ambulatory visits though some have begun to incorporate remote patient monitoring (RPM) [5, 9]. RPM is a form of telemedicine that uses home-based digital health technologies to collect and transmit patient data to the health care team. This allows for patient monitoring outside of conventional clinical settings. A surge in applications of RPM programs across medical disciplines has been reported in recent years [10, 11]. However, few studies have focused on parental perspectives related to their participation in early discharge programs, that include RPM or otherwise, and these have largely been conducted in Scandinavian countries where the healthcare infrastructure, support systems, and cultural norms differ from those in the United States [2 , 9]. Parent perspectives are crucial to learning how we can support families in their transition to home with remote monitoring.

In May 2019, the NICU at Oregon Health & Science University (OHSU) launched an RPM program called “Growing @ Home” (G@H) for infants admitted to the NICU who remain hospitalized only for continued nasogastric tube feeds. These infants are eligible for discharge home with ongoing daily remote support from the G@H team. We sought to explore parental experiences with G@H, including preparing for transition to home, the benefits and drawbacks of RPM, and opportunities for program improvement.

2 Methods

2.1 Study Setting

The Doernbecher Children’s Hospital NICU is a level IV regional referral center with 46 open-bay beds located in Portland at OHSU, Oregon’s only academic health center. It is family-centered: parents can be present at any time and have access to services that include NICU-based lactation specialists, clinical psychologists, and respiratory, physical, and occupational therapy.

2.2 Growing @ Home Program

Infants eligible for G@H include those admitted to the NICU who have achieved all milestones for discharge except for needing continued NG tube feeding support. Additionally, infants must be at least 35 weeks’ post-menstrual age, weigh at least two kilograms, have stable vital signs without history of recent apnea events, be able to take at least 30% of daily feedings by mouth, and be gaining weight on their current feeding regimen. Families must demonstrate consistent involvement in care during the NICU stay, have a stable method of telephone communication, and agree to all aspects of home NG tube feeding, including replacement of the NG tube if necessary. Families are excluded if the infant is unable to safely feed by mouth, psychosocial instability exists in the home as determined by a multidisciplinary NICU team, or the family’s primary language is other than English or Spanish (the infant monitoring application is currently only available in these languages).

In addition to routine NICU discharge education, families are provided with and taught to use a tablet equipped with the RPM application accessible to G@H providers, an infant scale, and feeding supplies. The infant’s primary care provider is notified of the infant’s participation in the program and follow-up visits have been scheduled with the infant before hospital discharge. After NICU discharge, parents securely enter data used to track their infant’s progress at home, similar to how progress is monitored in the hospital. Families input weight; volume taken by bottle, breast, or NG tube; and number of stool and urine events daily. Families have required daily telephone contact with a NICU provider who has reviewed the feeding and weight data entered into the RPM application by the family. This daily support continues until the infant is able to take all feedings by mouth, plus an additional five to seven days to ensure stability and growth. Parents are instructed that the RPM tablet is not an emergent form of communication, that they should contact the PCP if urgent issues or questions arise or if parents have non-feeding related concerns. If the G@H team needs to be contacted prior to the next scheduled phone call, the family can call the OHSU NICU. In addition to support of the G@H team and follow-up with the infant’s primary care provider, some families meet with a speech therapist and dietician every 2-4 weeks as needed. After discharge from G@H, parents return the scale and the RPM tablet to the NICU.

Between May 2019 and August 2022, 132 infants have been enrolled in the program. Eligible families decline participation about 15% of the time, with the main reason cited as discomfort with managing the NG at home.

2.3 Recruitment and Setting

Recruitment for this study began in March 2020; parents of all infants who had been enrolled in and discharged from G@H between May 2019 and March 2020 were invited to participate in the current study. Participants were recruited by mail invitation sent to their home address. Recruitment materials included an information sheet that described the study in detail and an invitation to take part in key informant interviews. Parents who expressed interest e-mailed author CGC to arrange for an interview time. We conducted recruitment telephone follow-up with those who did not respond to the initial mailing. All participants resided in the Pacific Northwest. All study activities were reviewed and approved by OHSU’s Institutional Review Board. Receipt and review of the information sheet, which served as the study consent, was verbally confirmed with all participants prior to the start of the interviews. All participating parents provided verbal consent for this study.

2.4 Parent interview data collection

All interviews were conducted over the phone between March 26 and April 3, 2020 due to COVID-19 safety restrictions that prohibited in-person interviews. The interview guide contained 13 questions (Table 1) some of which were adapted from a previous study [9], and clarifying prompts were used to further explore and/or confirm our understanding of study subjects’ responses. Author CGC is a neonatologist and was the lead facilitator for the interviews. Author PAC is a PhD qualitative researcher and co-facilitated by contributing prompts to dive deeper and further elucidate responses. Both CGC and PAC fully participated in all telephone interviews and each took field notes. Interviews lasted between 16 and 67 minutes (Mean = 31.7 minutes). Field notes from all interviews were combined into a single composite document for analyses.

Table 1
Key Informant Interview Schedule

Background/demographic information:

1. Parent age:

2. Relationship to baby (self-defined):

3. How many other children they have had:

4. Highest level of education:

Semi-Structured Interview Questions

1. Tell me about the few days before discharge in which you were preparing to take (infant’s name) home.

a. Probe: How were you feeling?

b. Probe: What do you wish you had known or done prior to discharge?

2. Tell me about a typical day at home while participating in this program

3. Describe what the Growing at Home Program has meant for you

4. Describe what the Growing at Home Program has meant for your family

5. Describe your relationship to your baby during the Growing at Home Program

6. What are some of the benefits of discharging home on “Growing at Home?”

7. What are some of the drawbacks of discharging home on “Growing at Home?”

8. How did you make decisions about your infant’s care while participating in the Growing at Home program?

9. Describe the guidance you got from the Growing at Home team

10. How was your experience with the technology used?

11. What would you advise another parent in a similar situation who is contemplating discharging home on Growing at Home versus staying in the NICU?

12. Some people might say it would be easier to have their infant cared for in the NICU than at home. What would you say to that?

13. What would you change about the Growing at Home program?

Background/demographic information:
1. Parent age:
2. Relationship to baby (self-defined):
3. How many other children they have had:
4. Highest level of education:
Semi-Structured Interview Questions
1. Tell me about the few days before discharge in which you were preparing to take (infant’s name) home.
a. Probe: How were you feeling?
b. Probe: What do you wish you had known or done prior to discharge?
2. Tell me about a typical day at home while participating in this program
3. Describe what the Growing at Home Program has meant for you
4. Describe what the Growing at Home Program has meant for your family
5. Describe your relationship to your baby during the Growing at Home Program
6. What are some of the benefits of discharging home on “Growing at Home?”
7. What are some of the drawbacks of discharging home on “Growing at Home?”
8. How did you make decisions about your infant’s care while participating in the Growing at Home program?
9. Describe the guidance you got from the Growing at Home team
10. How was your experience with the technology used?
11. What would you advise another parent in a similar situation who is contemplating discharging home on Growing at Home versus staying in the NICU?
12. Some people might say it would be easier to have their infant cared for in the NICU than at home. What would you say to that?
13. What would you change about the Growing at Home program?

2.5 Data coding and analyses

We used classical content analysis that included an inductive and iterative process of open and axial coding and constant comparative analysis to identify emergent themes, their definitions, and relationships amongst themes [12]. Both authors CGC and PAC, who have qualitative research training, independently coded the final consensus field notes document, then held consensus meetings to review and discuss codes, and their definitions and relationships, until analyses were finalized. The consensus meetings were needed to identify or recognize possible biases based on the position of the investigators in this study. Individual study identifiers were assigned to participant interviews, which allowed us to keep track of the number of codes and respondents associated with emergent themes, and in which interviews they occurred. After all initial codes had been applied, a second round of coding/re-coding of all interview documents was employed to assure both congruence and that codes were specific and inclusive.

3 Results

A total of 12 interviews were conducted that included 13 parents reporting on 11 G@H experiences. One set of parents was interviewed together, and one set was interviewed separately. All birthing parents in this study self-defined their parenting role as “mother” and the two participating male partners defined themselves as “father.” Nine interviews were conducted with only the mother of the infant. The average parent age was 34.5 years (range 22–40) (Table 2). About half of the families had no other children at home, and parents with other children had either one or two at home. Most parents had a college education (Table 2).

Table 2
Characteristics of 13 Parents Interviewed About Their Experience with the Growing at Home Program

Interview Interview Length (min) Parent Age Self-Defined Relationship to Infant Number of Other Children Highest Educational Level

1 52 35 Father 0 Master’s Degree

2 48 34 Mother 0 Master’s Degree

3 30 38 Mother 1 4 Years of College

4 35 40 Mother 1 Post Grad Certificate

5 67 34 Mother 0 Associate’s Degree

6 36 38 Mother & 1 Master’s Degree

7 38 Father v Master’s Degree

8 21 22 Mother 2 High School

9 27 36 Mother 0 Bachelor’s Degree

10 34 36 Mother 1 Bachelor’s Degree

11 16 34 Mother 0 Juris Doctor

12 22 35 Mother 0 High School

13 24 29 Mother 0 Some College

Interview	Interview Length (min)	Parent Age	Self-Defined Relationship to Infant	Number of Other Children	Highest Educational Level
1	52	35	Father	0	Master’s Degree
2	48	34	Mother	0	Master’s Degree
3	30	38	Mother	1	4 Years of College
4	35	40	Mother	1	Post Grad Certificate
5	67	34	Mother	0	Associate’s Degree
6	36	38	Mother &	1	Master’s Degree
7		38	Father	v	Master’s Degree
8	21	22	Mother	2	High School
9	27	36	Mother	0	Bachelor’s Degree
10	34	36	Mother	1	Bachelor’s Degree
11	16	34	Mother	0	Juris Doctor
12	22	35	Mother	0	High School
13	24	29	Mother	0	Some College

3.1 Primary Overarching Theme: Establishing Normalcy

The primary emergent theme and sub-themes derived by the consensus process are included in Table 3. By far, the primary emergent theme was the desire to return to normalcy, which was expressed as a driving factor for participating in G@H. Parents conveyed being highly motivated to bring their infant home early because establishing roles, relationships, and routines were their top priorities. They reported feeling compelled to establish a ‘new normal’ for their family by incorporating their new infant into family life as soon as possible. As one parent plainly stated, ‘Life feels like it’s on hold while in the NICU.’ Parents reported the G@H program supports families in this endeavor by facilitating earlier discharge.

Table 3
Emergent Themes and Exemplars

Thematic Contributions to the G@H Experience Exemplars

Primary Overarching Theme: Establishing Normalcy •‘Life feels like it’s on hold while in the NICU.’ (Interview #6).

•‘The NICU is no place for new parents.’ (Interview #13).

•‘It’s a hospital. It’s noisy. It doesn’t feel like home.’ (Interview #12).

Secondary Sub-Theme: Preparing for Home •‘The baby ate better when one of us (parents) fed him, so we took this over pretty quickly.’ (Interview #13).

•‘We felt very well prepared. We were trained well and felt confident with the information and support we received.’ (Interview #1).

•‘We felt very overwhelmed. It was scary.’ ‘We were so afraid we would have to replace the feeding tube.’ (Interviews #6, #7).

Secondary Sub-Theme: Adjusting to Home •‘The nurses let us know, “It doesn’t have to be perfect”, which relieved some of the pressure we felt to stick to a schedule. (Interview # 4).

•‘Being at home meant my husband could see the baby every day. He just could not take time away from his job to come to the NICU.’ (Interview #12).

•‘It was great to not need permission to do things –much less stressful.’ (Interview #9).

•‘My daughter finally got to meet the baby and see her regularly.’ (Interview #6).

•‘We were finally parents . . . took a while to feel like we had our own child.’ (Interview #1).

Secondary Sub-Theme: Relationships &Bonding •‘She felt more real at home, and I wasn’t constantly afraid that she was going to die.’ (Interview #3).

•‘I had trouble bonding with my first child who also required a NICU stay, and I was very worried the same thing would happen. I was grateful that this program shortened the NICU stay and accelerated bonding.’ (Interview #10)

•‘If we stayed in the NICU, I would likely have pushed bottle feeding so we could discharge sooner, but being home allowed me to prioritize breastfeeding which was successful.’ (Interview #2)

Secondary Sub-Theme: Health, Wellness, and Financial Security •‘It’s much easier to take care of yourself when at home. You can take a shower.’ (Interview #13).

•‘If we had stayed in the NICU through New Year’s, our deductible would have reset, causing additional costs.’ (Interview #2).

•‘The resources for a continued NICU stay simply for feeding issues would have been a “waste.”’ (Interview #1).

•‘Driving back and forth to the NICU was exhausting.’ (Interview #3).

Secondary Sub-Theme: G@H Team Support Process •‘NICU provided the confidence that you can do this . . . This is my baby, and I can take care of her.’ (interview #4).

•‘Part of the G@H program is to transition “parents into primary care providers” and to “wean” the guidance needed over time.’ (Interview #1).

•‘It put us in the driver’s seat. I felt very much in charge . . . I was the one communicating with the health care team regarding her weight, eating, pooping . . . I could get her what she needed.’ (Interview #2).

3.2 Sub-Theme: Preparing for Home

Many parents revealed that preparation for discharge started early in the NICU, with a steady transfer of responsibilities to parents to help them learn to care for their infants in this setting (some parents felt more included than others). They learned a care schedule in the NICU that helped develop a rhythm they continued at home. While many expressed eagerness for discharge, they also expressed fear and anxiety about caring for their infant. Some parents indicated that their discharge process felt hurried. Some revealed they found out about the G@H program only a few days prior to discharging home. Others indicated it felt rushed because of the tasks they needed to accomplish and the amount of information they received prior to discharge. Learning to place the feeding tube was a specific stressor for several parents, and that anxiety often resolved with practice. All ultimately felt fully prepared for discharge home and comfortable with the protocols for the G@H program.

3.3 Sub-Theme: Adjusting to Home

Once home, several families drew on their experience of having seen nurses troubleshoot tube feeds and other issues that helped them to do the same. Nurses also demonstrated flexibility that ‘it doesn’t have to be perfect’ which helped parents explore alternative strategies. Being home gave them a sense of freedom and control they lacked in the NICU. They were able to have family and friends visit and bond with their infant without restrictions. They could eat while holding their infant, nap, attend to chores, and they did not have to commute to and from the hospital. They were able to attend to their infant at night instead of having to leave them in the care of others in the NICU. While some acknowledged they may have slept more at home at night while their infant was an inpatient, they often worried about their infant at night and overall felt much better having them home. Many expressed that they did not feel like their infant’s primary caregiver until they came home and took over all care. One parent summed this up as ‘We were finally parents!’

3.4 Sub-Theme: Relationships & Bonding

Parents indicated that discharging home allowed for enhanced bonding with their infant. Some described that in the NICU they perceived their infant as sick and that this perception shifted. They spoke about the cords and wires attached to their infant in the NICU that made it difficult to hold them and contributed to the image of their infant as “sick” and how at home it was much easier to hold and bond with them. Many conveyed how well their infants have been doing since discharge and they appreciated the bonding that was fostered by being home and away from the chaotic NICU setting.

Mothers described the NICU as an overwhelming, intimidating, and difficult place to attempt breastfeeding, even with support from the lactation team and nurses. They described the cramped nature of the NICU and the lack of privacy due to the open-bay layout as challenging, despite use of privacy screens. They found it much easier to work toward breastfeeding in the comfort of their home.

3.5 Sub-Theme: Health, Wellness, and Financial Security

The majority of parents felt it was easier to care for themselves at home. They had better physical and mental health, and could focus on their relationships with their infant, partner, family, and friends. They felt less stress overall and felt it was a better environment for their infant. However, one mother described an initial impatience to discharge home with this program followed by a deterioration in her own health and wellness as she became exhausted and overwhelmed with infant care at home. Much of this stress was due to her being the primary caregiver for the infant as her spouse had to return to work, having used his paternity leave when the infant was in the NICU.

Parents indicated that several financial benefits to discharging early from the NICU exist, such as time and money saved by discharging home earlier. One family relayed concerns their deductible would have reset had they stayed through the new year. Some were able to cut childcare costs for older siblings once the infant discharged home. Many described being relieved that the commute to and from the hospital ended and the various resources (time, money, stress) that this required was behind them.

3.6 Sub-Theme: G@H Team Support Process

Starting in the NICU and continuing with the G@H team, parents indicated they felt reassured and encouraged in a way that made them feel empowered and confident to care for their infant. Once home, many felt there was an evolution in decision-making over time. At first, many parents indicated they relied more heavily on the G@H team but as time went on, they made more and more decisions for themselves. Other parents felt more comfortable making decisions from the beginning. Almost all families felt fully supported by the team and felt comforted knowing they had someone they could contact for questions and guidance. They felt the daily phone calls were appropriate in frequency and content. The technology was unanimously described as easy to use, and the burden of data recording was felt to be manageable and well worth being able to have their infant home early.

Some parents expressed frustration when different members of their infant’s care team (RPM team, primary care provider, feeding team, lactation, etc) provided conflicting messages about their infants’ care. When the responsibilities of these members/teams were not well-defined, confusion reigned. Two families felt it was difficult to troubleshoot some things over the phone, such as managing reflux or vomiting. Others felt they hadn’t been well prepared for the burden of outpatient appointments they were required to attend. Some described the daily phone calls as sometimes unnecessary, while others found comfort in the daily call and even wished for longer contact with the team after being discharged from G@H, suggesting the program could benefit from tailoring elements to meet parental needs.

While all participating parents expressed gratitude for this program and the ability to take their infant home from the NICU sooner, many acknowledged that this program may not fit the needs of every family or infant, and that parents should be well prepared and fully comfortable before deciding to take part in the program.

4 Discussion

Admission of infants to neonatal intensive care units (NICU) causes substantial stress among parents, especially mothers [13 –18] The NICU environment is an especially stressful setting, primarily due to noise, continuous monitoring, and visitation restrictions [19, 20] This environment has been shown to negatively affect parent-infant bonding [17 , 21–23]. Our results corroborate these findings and suggest that early discharge from the NICU could mitigate some of these stressors. We found that a primary driver of participation in G@H was that families yearn for normalcy and to resume their expected life with the addition of their new infant, which had been interrupted by the need for NICU care. This RPM program allowed them to transition home sooner and take over primary care of their infants, which made them feel more like parents and a family compared to the NICU setting. They found it easier to maintain their own health/wellness, consider unexpected financial strains, and prioritize bonding with their infant at home than in the NICU.

Families’ observations and processing of NICU activities indicates that additional opportunities exist for how the transition from the NICU to home can be further smoothed. Hearing parents reflect that they did not really feel like parents until they were home emphasizes the importance of involving parents in infant care early and often during their infants’ time in the NICU. Their observations also indicate that families are watching and learning from what is done and said in their company, both positive and negative.

While most parents felt well-prepared and supported in their transition to home, a few parents felt rushed, which highlights the importance of preparing parents early in the discharge planning process. This is an area the G@H program is currently working to improve, including introduction to the program earlier in the hospitalization, though not too early, as it can be overwhelming, and practicing more G@H tasks prior to discharge. In addition, the idea of replacing the NG tube did cause some anxiety that could potentially be better addressed with more practice in the NICU.

We were fortunate to hear the account of a mother who struggled with mental wellness upon discharge. This emphasized the need for an objective assessment of parental well-being, for which the Edinburgh Postnatal Depression Scale has been incorporated into the G@H program, and the importance of highlighting options to families for increased support from the G@H team and/or an option for readmission.

This exploratory study is unique in that it presents in-depth qualitative findings from a program that included infants discharged early from the NICU in the United States and that utilized RPM technology. The majority of prior studies on parent perspectives were conducted elsewhere making direct comparisons to other studies is challenging [2 , 9]. Limitations include relatively small sample size, which did not allow us to reach full thematic saturation. However, this study lays a foundation upon which to conduct a larger future assessment. Only one hospital’s program was included, which may limit transferability of findings. We included some parents who participated in the RPM program almost a year prior to the interview; recall bias may have affected their responses. While both parents for each infant in this study were invited to participate, mothers were the primary participants. They often stated they were better able to answer questions about the RPM program, having been the primary caretakers during their infant’s early weeks home. Future studies of the fathers’ perspectives would be important to conduct. The majority of participants tended to be college graduates with many having post baccalaureate degrees, which could have affected how families responded to the questions asked or to participation in the program itself. Finally, there is methodological debate about the use of field notes versus audio recording in qualitative research. However, a comparative analysis shows that the data quality collected between the two methods is similar in detail suggesting either method can be appropriate [24]. We found our field notes were very similar and our consensus process was strong.

Future studies with more participants are needed to further elucidate the themes that have emerged from this study. How NICUs and RPM programs can facilitate the transition of parents into the primary caregiver role, enhance parent-infant bonding, and support breastfeeding are of particular interest for future research. Additionally, the impact of having additional support systems from other family members as part of the program, and identifying characteristics of families who would be best served by a home based monitoring program or by a traditional inpatient stay until monitoring is no longer needed for the infant should be explored.

5 Conclusion

We identified both benefits and challenges of facilitating early discharge with an RPM program such as G@H. Perhaps the most important benefit identified by parents was the gift of time and space with their infants and what being together meant for their family as they achieved normalcy. Programs like this can help reconcile the expected delivery course with the reality of having an infant who requires NICU care. This study also highlights potential areas of improvement in helping parents cope during the NICU stay and as they transition to home. Further, this study can serve as a reminder that this type of program may not suit all families and that, as always, providing medical care is a highly individualized process.

Footnotes

Acknowledgments

We are grateful to the parents who participated in the Growing @ Home program and those who allowed us to conduct key informant interviews with them. We would like to thank Dr. Katharine Zuckerman, MD, MPH, for her critical review of this manuscript.

Disclosures

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical Approval/Patient Consent

All study activities were reviewed and approved by OHSU’s Institutional Review Board, Study# 00021254. Participants received information sheets in the mail. Receipt and review of the information sheet, which served as the study consent, was verbally confirmed with all participants prior to the start of the interviews. All participating parents provided verbal consent for this study.

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Thematic Contributions to the G@H Experience	Exemplars
Primary Overarching Theme: Establishing Normalcy	•‘Life feels like it’s on hold while in the NICU.’ (Interview #6).
	•‘The NICU is no place for new parents.’ (Interview #13).
	•‘It’s a hospital. It’s noisy. It doesn’t feel like home.’ (Interview #12).
Secondary Sub-Theme: Preparing for Home	•‘The baby ate better when one of us (parents) fed him, so we took this over pretty quickly.’ (Interview #13).
	•‘We felt very well prepared. We were trained well and felt confident with the information and support we received.’ (Interview #1).
	•‘We felt very overwhelmed. It was scary.’ ‘We were so afraid we would have to replace the feeding tube.’ (Interviews #6, #7).
Secondary Sub-Theme: Adjusting to Home	•‘The nurses let us know, “It doesn’t have to be perfect”, which relieved some of the pressure we felt to stick to a schedule. (Interview # 4).
	•‘Being at home meant my husband could see the baby every day. He just could not take time away from his job to come to the NICU.’ (Interview #12).
	•‘It was great to not need permission to do things –much less stressful.’ (Interview #9).
	•‘My daughter finally got to meet the baby and see her regularly.’ (Interview #6).
	•‘We were finally parents . . . took a while to feel like we had our own child.’ (Interview #1).
Secondary Sub-Theme: Relationships &Bonding	•‘She felt more real at home, and I wasn’t constantly afraid that she was going to die.’ (Interview #3).
	•‘I had trouble bonding with my first child who also required a NICU stay, and I was very worried the same thing would happen. I was grateful that this program shortened the NICU stay and accelerated bonding.’ (Interview #10)
	•‘If we stayed in the NICU, I would likely have pushed bottle feeding so we could discharge sooner, but being home allowed me to prioritize breastfeeding which was successful.’ (Interview #2)
Secondary Sub-Theme: Health, Wellness, and Financial Security	•‘It’s much easier to take care of yourself when at home. You can take a shower.’ (Interview #13).
	•‘If we had stayed in the NICU through New Year’s, our deductible would have reset, causing additional costs.’ (Interview #2).
	•‘The resources for a continued NICU stay simply for feeding issues would have been a “waste.”’ (Interview #1).
	•‘Driving back and forth to the NICU was exhausting.’ (Interview #3).
Secondary Sub-Theme: G@H Team Support Process	•‘NICU provided the confidence that you can do this . . . This is my baby, and I can take care of her.’ (interview #4).
	•‘Part of the G@H program is to transition “parents into primary care providers” and to “wean” the guidance needed over time.’ (Interview #1).
	•‘It put us in the driver’s seat. I felt very much in charge . . . I was the one communicating with the health care team regarding her weight, eating, pooping . . . I could get her what she needed.’ (Interview #2).