Very premature babies aren’t getting the follow-up care that they need. Premature babies are very often born to women who have risk factors, including low-income and drug use. This means that medically fragile, high needs babies are going home to women who may not have the resources to care for them or even get appropriate medical care.
The best answer would be an integrated medical system, where hospital care is automatically connected to social services and outpatient care. Right now, parents have to find follow-up services themselves in most places, assisted perhaps by a booklet or a list of phone numbers.