A recent federal law has expanded the eligibility for multidisciplinary evaluation and assessment of infants suspected of developmental delay. At the same time, modern neonatal care has increased infant survival. These two developments have created a need for family education regarding the need for health and developmental intervention, as well as counseling to maintain family participation in these services. This study compares the education and counseling services of a hospital-based case management team with the traditional discharge and follow-up services of a neonatal intensive care unit (NICU). Subjects were the 10% most medically severe infants discharged from a neonatal intensive care unit over a 16-month period. Preliminary data suggests a significantly greater number of families accessed community-based, coordinated, comprehensive health and developmental services when they received case management services. The data suggest that hospital professionals generally refer the most medically severe 3% of this group for services under a traditional model. However, the additional 7% referred under the transition model showed greater developmental benefits from the services during the first 6 months of life. These data support current federal initiatives for early intervention services which are family-centered, community-based and coordinated.